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CLINICAL 
SURGICAL  DIAGNOSIS 

FOR 

STUDENTS   AND    PRACTITIONERS. 


BY 

F.   DE   OUERVAIN 

Professor  of  Surgery  and  Director  of  the  Surgical  Clinic  at  the  University  of  Basle 


WITH   510   ILLUSTRATIONS   AND   4    PLATES 


Translated  from  the  Fourth  Edition  by 
J.  SNOWMAN,   M.D. 


NEW     YORK 

WILLIAM     WOOD     AND     COMPANY 

MDCCCCXIII 


55 


3r 


^  u- 


f 

I      AUTHOR'S    PREFACE    TO  THE   ENGLISH 

EDITION. 

Thjs  book,  the  English  version  of  which  affords  me  special 
pleasure,  is  the  outcome  of  years  of  association  with  students,  as 
I  teacher,  and  with  medical  practitioners  at  consultations.  '  It  is 
ntended  to  serve  as  a  guide  to  the  former  in  the  vast  field  of  surgical 
iiagnosis  which  they  are  required  to  explore,  and  to  recall  to  the 
after  knowledge  which  has  perhaps  faded,  while  drawing  their 
ittention  to  new  developments  in  diagnosis.  To  this  end  I  have 
employed  the  methods  of  investigation  which  are  available  for 
he  general  practitioner,  or  at  any  rate  which  can  easily  be 
:arried  out  for  him.  These  methods  comprise  the  bacteriological, 
serological,  histological  and  radiographic  researches,  without  which, 
lowadays,  a  reliable  diagnosis  cannot  be  obtained. 

I  adhere  throughout  to  the  plan  of  starting  with  the  symptoms 
A^hich  caused  the  patient  to  seek  medical  advice,  and  not  to  the 
nethod  of  deducing  symptoms  from  an  already  made  diagnosis. 

If  the  appropriate  questions  have  been  correctly  put,  the  problem 
vill  in  every  case  be  narrowed  down  more  and  more,  until,  ultimately, 
he  student  arrives  at  a  definite  diagnosis,  either  as  the  result  of 
Dositive  symptoms  or  by  a  process  of  gradual  exclusion.  After 
ong  training  in  this  method,  the  student  may  be  permitted  to 
:liagnose  a  case  as  a  whole,  without  first  considering  each  symptom 
separately.  One  thing,  however,  must  be  borne  in  mind.  Important 
IS  it  is  to  have  an  accurate  diagnosis,  our  endeavours  to  obtain  one 
iare  not  entail  injury  to  the  patient,  nor  involve  the  loss  of  the  most 
Hvourable  moment  for  a  successful  operation,  while  refinements  of 
iiagnosis  are  being  investigated.  A  diagnosis  is  not  to  be  made 
iierely  for  its   own  sake,  but  as  a  means  to  a  cure. 

This  book  represents,  above  all,  the  fruit  of  my  own  experience, 
md  the  illustrations  are,  with  a  few  exceptions,  derived  from  my 
)wn  observations.  The  contents  may,  in  consequence,  be  necessarily 
ncomplete  in  certain  particulars,  but  I  trust  that  this  is  compensated 
or  by  vividness  of  description. 

F.    DE    QUERVAIN. 

Basle,  February,  19 13. 


Digitized  by  the  Internet  Arciiive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/clinicalsurgicalOOquer 


CONTENTS. 


PART    I. 
SURGICAL    DISEASES    OF    THE    HEAD. 

I.— FRACTURES  OF   THE  SKULL 

I. — Direct  Symptoms    

2. — Indirect  Symptoms 

IL— INJURIES  OF  THE  BRAIN 
I. — Concussion'  of  the  Brain 
2. — Contusion  of  the  Brain  ... 
3. — Cerebr.al  Pressure  following  H.f:morrhage 

III.— ABSCESS    OF    BRAIN,    HEMORRHAGIC    PACHY- 
MENINGITIS, CYST  OF  BRAIN,  TUMOUR  OF 

BRAIN  

I. — Abscess  of  Br.ain 

2. — Hemorrhagic  Pachymeningitis  

3. — Traumatic  Cysts  of  the  Br.ain 

4- — New    Growths    .and    Tumours    of    Granulation- 
Tissue        


PAGE 

I 
2 
4 

7 
8 

10 


17 
18 
20 
21 


OF     SUP- 


IV.— THE      CEREBRAL      COMPLICATIONS 

PURATIVE  OTITIS  MEDIA  

v.— THE  PROBLEM  OF  EPILEPSY 

VI.  -SOME  REMARKS  ON  CEREBRAL  LOCALIZATION 
AND  FOCAL  DIAGNOSIS       

VII.— THE  SURGERY  OF  EXOPHTHALMOS  

VIII. —ACUTE    INFLAMMATORY    PROCESSES    ON    THE 
SKULL  

IX.— SWELLINGS  OF  THE  HEAD       

A. — Congenit.al  Swellings  of  the  Head 

B. — ACQUIRED  Swellings  of  the  Head      

I. — Innocent   acquired   Swellings 

2. — Malignant    Tumours    of    the    Head   and   Chronic 
Inflammatory    Swellings   ... 

X.— ACUTE     INFLAMMATORY     DISEASES     OF     THE 
FACE  

XL— TUMOURS  AND  ULCERS  OF   THE   FACE 

A. — Tumours  with  Overlying  Skin  unbroken 

B. — Ulcerative  Processes      

XII.— INJURIES  OF  THE  J.\W 

XIII.— LOCK-JAAV  


25 

34 

38 

49 

51 


56 

59 

62 
62 
64 

7?> 

75 


Vlll.  CONTEXTS 


PAGE 


XXX.— TUMOURS     AND    ALLIED     GROWTHS     AVITHIN 

THE   THORAX      iqq 

I. — Mediastinal  Tumours      199 

2. — Tumours  of  the  Lung 207 

XXXL— SWELLINGS  AND   TUMOURS   OF   THE   THORAX  208 

A. — Primary  Disease  within  the  Thorax  208 

B. — Primary  Disease  of  the  Thoracic  Wall      ...        ...  210 

I. — Acute  Diseases  ...         ...         ...         ...         ...         ...  210 

2. — Chronic   Diseases         ...         ...         ...         ...         ...  211 

a. — Chronic  Inflammatory  Processes         ...  ...  211 

b. — Tumours       ...         ...         ...         ...         ...         ...  216 

XXXIL— INFLAMMATORY  DISEASES  OF  THE  BREAST  ...  219 

I. — Acute  Inflammations       219 

2. — Chronic  Inflamm.ations 221 

XXXIIL— TUMOURS  AND  ALLIED  STRUCTURES   IN   THE 

BREAST        223 

A. — Multiple  Tumours  ...  224 

B. — Single   Tumours 224 

I. — Small  and  Medium-sized  Tumours  ...  ...  224 

2. — Large   Tumours  ...  ...  ...  ...  ...  232 


PART    IV. 

SURGICAL    DISEASES    OF   THE    ABDOMINAL 
AND    PELVIC    VISCERA. 

XXXIV.— DISPLACEMENTS  OF  THE  ABDOMINAL  VISCERA  235 

XXXV.— ABDOMINAL    INJURIES '244 

A. — Injuries  without  an  Open  Wound 244 

-Gastro-intesnnal    Canal  ...  ...  ...  ...  245 

-The  Spleen         ...         ...         ...         ...         ...         ...  247 

-Liver  and   Bile    Ducts  ...         ...         ...         ...  247 

-The   Kidneys      ...  ...  ...  ...  ...  ...  248 

-The   Bladder      ...  ...  ...  ...  ...  ...  250 

B. — Injuries  to  the  Abdomen  with  Open  Wounds      ...  251 

I. — Gun-shot  Wounds        ...         ...         ...         ...         ...  252 

2. — Stabs  and  Incised  Wounds  ...  ...  ...  ...  253 

XXXVI.— ACUTE      INFLAMMATION      WITHIN      THE     AB- 
DOMINAL  CAVITY       254 

A. — Abdominal  Pain  without  Perceptible  Changes  ...  261 

B. — Diffuse  Peritonitis  without  Localization  ...  263 

C. — Localized   Peritonitis     265 

I. — Epigastrium        ...  ...  ...  ...  ...  ...  265 

2. — Right  Hypochondrium  ...  ...  ...  ...  265 

3. --Left  Hypochondrium  ...  ...  ...  ...  ...  266 

4. — Lumbar  Regions  ...  ...  ...  ...  ...  266 

5. — Lower  Abdominal  Region 266 

6. — True  Pelvis        ...         ...         ...         ...         ...         ...  275 


CONTENTS  ix. 

PAGE 

XXXVII. ^SUB-PHRENIC  ABSCESS 276 

I. — Sub-phrenic  Abscess  without  Pleural  Effusion  ...  277 

2. — Sub-phrenic  Abscess  with  Pleural  Effusion         ...  279 

XXXVIII.— TUBERCULAR    PERITONITIS 281 

XXXIX.— DIAGNOSIS     OF     ABDOMINAL     SWELLINGS     IN 

GENERAL  287 

XL.— SURGICAL  DISEASES   OF   THE   STOMACH  ...  291 

A. — Foreign  Bodies  in  the  Stomach         292 

B. — Displacements  of  the  Stomach  293 

C. — Gastric  Ulcer        294 

I. — Uncomplicated  Gastric  Ulcer  ...  ...  ...  294 

2. — Haemorrhage       ...  ...  ...  ...  ...  ...  296 

3.— Perforation  ...  ...  ...  ...  ...  ...  296 

4. — Cicatricial  Stenosis      ...  ...  ...  ...  ...  299 

D. — Cancer  of  the  Stomach 305 

I. — Cancer  of  the  Body  of  the  Stomach         ...         ...  310 

2. — Cancer  of  the  Pylorus  ...  ...  ...  ...  311 

XLI.—SURGICAL  DISEASES  OF  THE  BILIARY  PASSAGES  313 

I. — G.all-stone   Colic 314 

2. — Acute  Cholecystitis         316 

3. — Gangrenous   Cholecystitis         318 

4. — Obstruction  of  the  Common  Bile-duct        321 

5. — Hydrops  of  the  Gall-Bladder,  Chronic  Empyema  323 

6. — Acute  Cholangitis  324 

XLIL— TUMOURS  OF  THE  LIVER  325 

XLIIL— SURGERY   OF    THE    PANCREAS  327 

I. — Acute  Pancreatitis  and  Pancreatic  H/Emorrhage  ...  328 
2. — Chronic  Pancreatitis,  Cancer  of  the  Head  of  the 

Pancreas,  Pancreatic  Calculus       329 

3. — Pancre.^tic  Tumours  and  Cysts  329 

XLIV.— SURGERY  OF   THE   SPLEEN       330 

I. — Abscess  of  the  Spleen      330 

2. — Splenic   Hypertrophy       330 

3. — Tumours  of  the  Spleen 331 

XLV.— ACUTE   APPENDICITIS     332 

XLVL— COLITIS,    SO-CALLED    CHRONIC   APPENDICITIS 
AND  FUNCTIONAL  DISTURBANCES  OF  THE 

LARGE   INTESTINE      339 

A. — Colitis  with  Definite  Anatomical  Changes  ...  339 

B. — Functional  Derangements  of  the  Large  Intestine 

without  Typical  Anatomical  Changes     342 

XLVII.— INTESTINAL   OBSTRUCTION 346 

I. — Stenosis  of   Gradual  Development   (Chronic   In- 
testinal Obstruction)  347 

^ — Symptoms  ...         ...         ...         ...         ...         ...  347 

^- — The  Position  of  the  Stenosis  ...         ...         ...  350 

c. — Form  and  Cause  of  the  Stenosis     ...         ...         ...  351 


CONTEXTS 

PAGE 

2. — Acute  Intestinal  Obstrixtiox 357 

a. — Symptoms           ...         ...         ...         ...         ...         ...  357 

h. — The  Position  of  the  Obstruction     ...          ...          ...  358 

c — The  General  Varieties  of  Acute  Obstruction     ...  360 

d. — Causes  of  Acute  Intestinal  Obstruction  ...         ...  361 

I. — Obstruction  due  to  Bands  and  Kinks             ...  361 

2. — Obstruction   by   Gall-stones       ...          ...          ...  362 

3. — Intussusception       ...          ...          ...          ...          ...  363 

4. — Volvulus       ...          ...          ...          ...          ...          ...  364 

5. — Strangulation   of   Internal   Hernia      ...          ...  365 

6. — Spastic  Obstruction           ...          ...          ...          ...  367 

XLVIIL— TUMOURS    AND     SWELLINGS    IN     THE    ABDO- 
MINAL PARIETES         368 

I. — The  Upper  Abdominal  Region 368 

2. — The  Umbilical  Region     371 

3. — INGUIN.AL    region 374 

4. — The  Lumbar  Region          375 

5. — Swellings  an^d  Tumours  in  Atypical  Positions  ...  376 

XLIX.— ABDOMINAL    SINUSES        377 

L.— EXTERNAL   INGUINAL   HERNIA         379 

I. — Diagnosis  in  the  Absence  of  Hernial  Swelling  ...  380 

2. — Diagnosis  of  Inguinal  Hernial  Swellings           ...  382 

3. — Diagnosis  of  Labial  and  Scrot.al  Hernia 387 

LL— INTERNAL  OR  DIRECT   INGUINAL  HERNIA     ...  390 

LIL— FEMORAL  HERNIA 392 

LIIL— TRAUMATIC  HERNL^        396 

LIV.— STRANGULATED    HERNIA           398 

I. — Is  the  Case  really  on^e  of  Hernia? ....  398 

2. — Is  THE  Hernia  str.-^ngulated  ? 401 

3. — What  does  the  Hernia  contain?        402 

4. — Where  is  the  Str.4ngulation  situated?        403 

5. — What  is  the  Condition  of  the  Str.angulated  Gut?  403 

6. — The  Questions  w^hich  may  arise  during  Operation  404 
7. — Questions   which  arise  after   Reduction  by   the 

Open  or  Bloodless  Method            ...        405 

LV.— DIFFICULTIES  OF  DEF^EXATION     407 

LVL— INJURIES  OF   THE  RECTUM     412 

LVIL— TUMOURS  AND  SWELLINGS  OF  THE  SCROTUM  414 

I. — Savellings  of  the  Scrotum        414 

a. — Acute  Swelling's            ...         ...         ...         ...         ...  414 

h. — Chronic  Swellings         ...          ...          ...          ...          ...  415 

2. — Swellings  of  the  Scrot.al  Contents          415 

a. — Tumours  of  the  Spermatic  Cord     ...         ...         ...  415 

b. — Acute  Swellings  of  the  Testicle  and  Epididymis  416 

c — Chronic  Sv\-ellings  of  the  Testicle  and  Epididymis  419 

I. — Swellings  of  the  Epididymis     ...          ...          ...  419 

2. — Swellings  between  the  Testicle  and  Epididymis  420 

3. — Swellings  of  the  Testicle           ...          ...          ...  420 

LVIIL— FISTULA  IN  PERINEAL  REGION       423 

I. — Dermoid  Fistul.^ 423 

2. — Fistul/e  in  Con*nection  with  Bone 424 

3. — fistul/e  of  the  rectum  and  anus    424 

4. — Urinary  Fistul.^ 426 


CONTENTS  xi. 

PAGE 


428 
428 
429 


LIX.-GENERAL       REMARKS       ON       THE       SURGICAL 

DISEASES  OF  THE  URINARY  ORGANS  ...     427 

A.— DISTURBA^-CES    OF    MICTURITION 

I- — Painful  Micturition      

2. — Difficult    Micturition 

<z.— Disturbances  of  the  Mechanism  of  Micturition  429 

i5.— Obstruction  of   the  Urethra       430 

3- — Deficient  Closure  of  the  Bladder 431 

4- — Vesical   Tenesmus        432 

B.-— Abnormal  Composition  of  the  Urine          433 

I. — Admixture  with  Pus 433 

2. — Admixture  with  Blood  435 

3.— Admixture     with     Inorganic    Deposits     or     Con- 
cretions (urinary  gravel) 436 

C. — Local  Symptoms     437 

LX.— INFLAMMATION  IN  THE  NEIGHBOURHOOD  OF 

THE    KIDNEY       442 

LXL— MOVABLE  KIDNEY 444 

LXIL— HYDRONEPHROSIS    AND    ITS    CONSEQUENCES     447 

LXIIL— IDIOPATHIC     SUPPURATION     IN     THE     RENAL 

PELVIS  AND  KIDNEY 450 

LXIV.-STONE  IN  THE  KIDNEY  AND  URETER     453 

A.— Primary  Stone  in  the  Kidney 453 

I- — Non-infected  Stone       ...          ...          ...          ...          ...  453 

2. — Infected  Stone   ...          ...          ...          ...          ...          ...  455 

B.— Secondary  Stone  in  the  Kidney          455 

LXV.— TUMOURS  OF  THE  KIDNEY      455 

LXVL— TUBERCULOSIS    OF    THE    URINARY    PASSAGES  458 

LXVIL— STONE  IN  THE  BLADDER  461 

LXVIIL— CYSTITIS  464 

LXIX.— TUMOURS  OF  THE  BLADDER 466 

I. --^Tumours  of  the  Mucous  Membr.^ne  of  the  Bl.^dder     466 
2.— Tumours  in  the  Muscular  Coat  of  the  Bladder  ...    467 

LXX.— HYPERTROPHY,    TUMOURS,    AND    ABSCESS    OF 

THE  PROSTATE 468 

I.— Hypertrophy  and  Tumours        468 

2. — Inflammatory   Processes  471 

LXXL— INJURIES  OF  THE  URETHRA 472 

LXXIL— SURGICAL  DISEASES  OF  THE  PENIS  474 

I. — Subcutaneous  Growths 475 

2. — Ulcerative  Changes ...  475 


Xll.  CONTENTS 

PART   V. 

SURGICAL    DISEASES    OF   THE    PELVIS   AND 
SPINAL   COLUMN. 

PAGE 

LXXIIL— TUMOURS  OF   THE  PELVIS       ...  478 

LXXIV.— CONGENITAL  ABNORMALITIES  OF  THE  SPINAL 

COLUMN      481 

LXXV.— LUMBAGO           486 

LXXVL— INJURIES  OF  THE  SPINAL  COLUMN           489 

I. — Method  of  Examination          48g 

11. — Diagnosis  of  the  Nature,  Degree,  and  Position 

OF  THE  Injury 493 

A. — The  Degree  and  the  Nature  of  the  Spinal  Cord 

Injury           493 

B. — The    Position   of   the    Spinal    Cord    Injury    (the 

Diagnosis  of  the  level  of  the  Lesion)           ...  495 
C. — Relations  between  the   Injury  to  the   Cord  and 

the  Vertebrae             ...         ...         ...         ...         ...  499 

D. — The    Form    of    the    Spinal    Injury            ...          ...  501 

I. — Fractures    of   the    Spinous  and    Transverse 

Processes             ...         ...         ...         ...         ...  503 

2. — Fracture  of  the  Vertebral  Arch          ...         ...  504 

3. — Compression  Fracture  ...          ...          ...          ...  505 

4. — Complete  Dislocation    ...         ...         ...         ...  506 

LXXVIL— THE  SURGERY  OF  NON-TRAUMATIC  DISEASES 

OF  THE  SPINAL  CORD          507 

I. — Is  A  Tumour  actually  present?          508 

2. — What  is  the  Nature  of  the  Tumour?          510 

3. — At  which  Level  is  the  Tumour  situated? 510 


LXXVIIL— INFLAMMATORY     DISEASES     OF     THE     SPINAL 

COLUMN      

A. — Tubercular  Caries  

I. — Tubercular    Caries    without    definite    Curvature 

and  without  a  Burrowing  Abscess 
2. — Spinal  Caries  with  Burrowing  Abscess  ... 
3. — Spinal   Caries  with  Curvature 
4. — Spinal  Caries  with  Cord  Symptoms 
B. — Non-tubercular     Inflammation     of    the     Spinal 
Column 

LXXIX. -SPINAL   CURVATURES       

I. — Antero-posterior  Curvatures 

2. — Lateral  Curvatures  


S" 

S-ii 

515 
SI9 
519 

520 

522 
526 


CONTENTS 


Xlll. 


PART    VI. 
SURGICAL  DISEASES  OF  THE   EXTREMITIES. 


LXXX. 


LXXXI. 


LXXXII. 


-FRACTURES      AND 
CLAVICLE    ... 


DISLOCATIONS      OF      THE 


-FRACTURES   AND  DISLOCATIONS   ABOUT   THE 

SHOULDER-JOINT         

A. — Dislocations  

B. — Fractures     

-INFLAMMATORY       PROCESSES      ABOUT       THE 

SHOULDER-JOINT         

A. — Distinction  between  Bursal  and  Joint  Disease  .. 
B. — Diagnosis  of  the  Various  Forms  of  Bursitis  and 
Arthritis  of  the  Shoulder 
I. — Bursitis     ... 
2. — Arthritis  of  the  Shoulder 
C. — Primary  Diseases  of  the  Bone 


LXXXIIL— INJURIES  ABOUT  THE  ELBOW-JOINT 

A. — Inspection 

B. — Examination  of  Elbow  Movements 

C. — P.ALPATION       

D. — Rontgen  Ray  Examination      

LXXXIV.— INFLAMMATORY   PROCESSES   ABOUT   THE 

ELBOW    

I. — Acute   Inflammatory  Processes  

2. — Chronic  Inflammatory  Processes      


page 
534 

537 

539 

5  4a 

547 
547 

55» 
550- 
550- 
553 

553 
554 
554 
S6o. 
567 

568 
568. 
571 


LXXXV. 
LXXXVI. 

LXXXVII. 

LXXXVIII. 

LXXXIX. 


-TUMOURS   AND    ALLIED   SWELLINGS    ON    THE 

UPPER  ARM  AND  FOREARM         572 

-INJURIES  OF  THE  WRIST  AND  HAND       576 

I. — Radius  and  Ulna 576 

2. — Wrist-joint 579 

3. — Metacarpus  and  Fingers  ...  ■      586 

-INFLAMMATORY       PROCESSES       ABOUT       THE 

WRIST  58S 

I. — Acute  Inflammations       588 

2. — Chronic  Inflammatory  Processes      589, 

-ABNORMAL  POSITIONS  AND  POSTURES  OF  THE 

HAND  AND  FINGERS 592 

A. — Results  of  Injuries  to  Nerves        592 

B. — Abnormal  Postures  of  the  Wrist-joint    595 

C. — Anomalies  in  the  Posture  of  the  Fingers 598 

-TUMOURS  OF  THE  HAND  AND  FINGERS  ...  599 

A. — Innocent  Tumours  599 

B. — Malignant  Tumours        600 


XIV. 


COXIEXTS 


XC— ACUTE    INFLAMMATORY    PROCESSES    OF    THE 

HAND  AND  FINGERS 601 

A. — IKFLAMMATORY   PROCESSES    OF   THE    FiXGERS     6oi 

B. — ACUTE   IXFLAMMATORY   PROCESSES   OF  THE   HAND  ...      605 

XCL— CHRONIC  INFLAMMATION  OF   THE  HAND  AND 

FINGERS      ...  605 

I.— The  Skix       605 

2. — The  Texdox-she.\ths        ...  607 

3.— The    Box-es 608 

-DISLOCATIONS  AND   FRACTURES  OF    THE   HIP 

A. — Method  of  Examix.atiox  

B. — Diagxosis  of  the  Various  Forms  of  Ixjury 

I. — Dislocations 

2. — Contusions,   Sprains,   Fractures 

-NON-TRAUMATIC   DEFORMITIES  AT   THE   HIP- 
JOINT      (CONGENITAL      DISLOCATION      OF 

THE  HIP  AND  COXA  VARA)  

A.— Coxgexital  Dislocation  of  the  Hip 

B. — Coxa   Vara 


XCII. 


XCIII. 


XCIV. 

xcv. 

XCVI. 


-ACUTE     INFLAMMATORY 
HIP-JOINT 


DISEASES     OF     THE 


-CHRONIC   INFL.AMMATORY   DISEASES   OF    THE 

HIP      

A. — Tubercular  Hip  Disease  

B. — Nox-tubercular  Chronic  Hip  Disease 

-SWELLINGS  AND  TUMOURS  OF  THE  THIGH 
A. — Swellings  of  the  Soft  Tissues 

B. — Swellings  of  the  Bone 

I. — Osteoma  and  Chondroma 
2. — Sarcomata  and  Allied  Tumours 
a. — Tumours  of  the  Epiphysis 
h. — Tumours  of  the  Diaph^'sis 


XCVII. 

XCVIII. 

XCIX. 


-INJURIES    IN    THE    VICINITY 
JOINT  


OF    THE    KNEE- 


-ACUTE    INFLAM^IATORY 
JOINT  


DISEASES    OF   KNEE- 


CHRONIC  DISEASES  OF  THE  KNEE  

I. — Chronic  Articular  Effusiox 

2. — fungailxg  intl.ammation  of  the  kxee-joixt 

3. — Rigidity         

TUMOURS   AND    ALLIED    STRUCTURES   ABOUT 
KNEE-JOINT         


C 
CI 
GIL— ULCERS  OF  THE  LEG 


SCIATICA  AND   OTHER  PAINFUL  DISEASES  OF 
THE    LOAVER   LIMBS 


CONTEXTS 

cm.— SWELLINGS  AXD  TUMOURS  OF  THE  LEG 

A. — Tumours       

B. — Inflammatory  Processes  

I. — Diffuse  Inflammatory  Processes 

2. — Circumscribed  Swellings 

CIV.— INJURIES  ABOUT  THE  ANKLE-JOINT 

I. — Injuries  without  Deformity     

2. — Injuries  avith  Deformity  

CV.— FRACTURE  OF  THE  OS  CALCIS 

CVL— INJURIES    TO    THE  FOOT,    IN    FRONT    OF    THE 
ANKLE-JOINT       

CVIL— INFLAMMATORY  DISEASES   OF    THE  FOOT 
A.— Tarsus  

I. — Acute  Diseases  ... 

2. — Chronic  Inflammations 
B. — Met,\tarsus  .^xd  Toes     

CVIII. ^DEFORMITIES  OF  THE  FOOT  , 

I. — Flat  Foot     

2. — Talipes,  Pes  equinus,  Pes  cavus,  Pes  calcaneus 
3-— 


-Deformities  of  the  Toes 


CIX.— TUMOURS  AND  ULCERS  OF   THE   FOOT 

I. — Tumours        

2. — Ulcers  


Intdex 


XV. 

PAGE 

697 
698 

700 
701 
703 

706 

706 
712 

716 


721 

724 
724 
724 

725 
728 

72Q 

729 
734 
12,7 

73  S 
738 
739 

741 


PART  I. 
SURGICAL   DISEASES  OF  THE  HEAD. 

CHAPTER  I. 
FRACTURES  OF  THE  SKULL. 

When  Dieffenbach  summarized  his  views  on  trephinin^i^,  in  his 
classical  work,  some  sixty  years  ago,  before  the  question  was  definitely 
settled,  he  wrote  as  follows  : — 

"  Up  to  quite  recently  it  was  the  first  urgent  duty  of  the  surgeon, 
immediately  after  the  injury,  to  make  a  large  crucial  incision,  and  to 
search  for  fissures  or  fractures.  Occasionally  I  found  on  my  arrival 
that  the  hairy  portion  of  the  head  had  been  ploughed  up  by  incisions, 
backwards  and  forwards,  crucial  and  transverse.  This  was  considered 
to  be  indispensable  in  all  head  injuries.  A  surgeon  who  had  omitted 
to  make  the  crucial  incision  would  have  incurred  the  same  responsi- 
bility as  one  who  failed  to  open  the  window  in  endeavouring  to 
rescue  a  victim  of  coal  gas  suffocation." 

At  that  time  there  was  no  *'  cerebral  diagnosis  "  ;  but  nevertheless 
the  surgeon's  need  for  a  diagnosis  had  to  find  some  expression.  To 
leave  an  injury  to  Nature,  without  knowing  whether  or  not  a  fissure 
was  present,  was  considered  to  be  an  unworthy  and  culpable  piece 
of  surgical  inactivity,  because  the  real  danger  of  a  fractured  skull  had 
not  yet  been  clearly  ascertained.  Philosophical  speculation  took  the 
place  of  observation,  and  therefore  surgery  for  a  long  time  was  guilty 
of  one  of  its  greatest  sins,  in  breaking  the  I'dw  priinimi  nil  nocerc.  We 
smile  at  this  kind  of  diagnosis  ;  but  posterity  will  look  upon  some 
of  our  exploratory  procedures,  involving  flaps  of  half  the  skull,  much 
in  the  same  way  as  we  regard  those  meaningless  "  crucial  and 
transverse  incisions."  The  maxim  "nil  nocere"  must  be  observed,  not 
only  in  treatment,  but  also  in  examination. 

The  term  "  fracture  of  the  skull  "  has  always  conveyed  to  the  lay 
mind  a  very  painful  impression  ;  but  we  have  learnt,  since  the  days 
when  trephining  was  epidemic,  that  it  is  not  the  fracture  of  the  skull, 
nor  even  its  splintering,  which  constitutes  the  danger,  but  the  injury 


2  SURGICAL    DISEASES   OF   THE    HEAD 

io  the  brain.  It  is  all-important  to  recognize  this,  because  this  alone 
can  justify  or  compel  interference.  The  study  of  injuries  to  tlie  sknll 
is  of  great  assistance  in  this  respect,  and  we  must  endeavour  to  gain 
a  precise  conception  of  them — not  by  pouring  pigment  on  the  exposed 
skull  after  the  manner  of  the  older  surgeons,  but  by  a  careful  con- 
sideration of  all  clinical  symptoms. 

(i)  DIRECT  SYMPTOMS. 

The  anatomical  structure  of  the  skull  frequently  conceals  the  usual 
symptoms  of  fracture ;  but  the  main  indications  are  always  present. 
The  symptoms  may  be  summarized  as  :  (i)  pain  at  the  seat  of 
fracture  ;  (2)  displacement  of  fragments  ;  (3)  unnatural  mobility,  and 
(4)  haemorrhage. 

(i)  The  pain  in  fractured  skull  may  be  evident  in  two  ways.  Pain 
on  direct  pressure  signifies  that  great  care  is  demanded.  A  limited 
area  of  tenderness  on  pressure  is  of  no  importance,  because  every 
bruise  is  eventually  painful.  But  a  definite  pain  persisting  along  one 
line,  for  several  days,  should,  at  any  rate,  suggest  the  probability  of 
a  complete  fissure.  Pain  may  also  be  elicited  at  the  seat  of  fracture, 
by  indirect  pressure,  either  by  compressing  the  whole  skull,  or  by 
applying  pressure  to  one  of  the  large  fragments.  This  sign  may  be 
important  in  the  case  of  fissures  ;  but  in  the  case  of  a  comminuted 
fracture,  the  unnatural  mobility  will  already  have  established  the 
diagnosis. 

(2)  Displacement  and  unnatural  mobility  only  occur  in  com- 
minuted fractures.  Displacement  manifests  itself  in  the  form  of  a 
depression — Depressed  fracture — and  unnatural  mobility,  by  resilience 
on  pressure.  These  two  symptoms  do  not  usually  occur  together  ; 
because  the  fragments  become  fixed  in  a  depressed  fracture,  and  the 
depression  remains  ;  whereas,  if  the  fragments  are  movable,  the 
intracranial  pressure  tends  to  replace  them,  and  the  original  depres- 
sion is  spontaneously  raised.  It  is  quite  easy  to  recognize  these 
symptoms,  and  either  of  them  is  conclusive  proof  of  a  comminuted 
fracture  of  the  roof  of  the  skull.  There  is  only  one  possibility  of 
error,  which  has  misled  even  experienced  surgeons  ;  whenever  any 
extensive  haemorrhage  occurs  under  the  aponeurosis,  or  especially 
under  the  periosteum,  the  effused  blood  feels  at  the  side  like  a  gently 
sloping,  thick  mound  with  a  sharp  edge,  corresponding  with  the 
blood-soaked  tissues ;  whereas  at  the  centre,  where  the  blood  collects 
in  a  larger  hollow  space,  the  consistence  is  softer,  and  to  the  examining 
finger  it  may  appear  as  a  depression.  It  makes  one  think  first  of  a 
depressed  fracture.  But  if  gradually  increasing  pressure  causes  the 
disappearance    of   the    mound-like    swelling,    at    any    one    spot,    it    is 


FRACTURES    OF   THE    SKULL  3 

obvioLis-h'  a  large  contusion — a  cephalhsematoma — and  not  a  depressed 
fracture. 

The  extensive  hcematomata  which  occur  in  alcohoHcs  tln^ough 
vascular  degeneration  easily  impart  to  the  finger  the  sensation  of 
having  penetrated  within  the  skull. 

A  young  female,  well  known  as  an  alcoholic  of  an  advanced  type, 
was  once  admitted  to  hospital  under  my  care.  Her  husband  had 
beaten  her  about  the  head  with  the  leg  of  a  chair,  so  that  it  resembled 
a  globular  mass  without  the  sign  of  a  human  feature.  The  scalp  was 
one  crackling  area,  and  I  was  convinced  that  a  severe  fracture  was 
present  beneath  it.  But  the  withdrawal  of  a  few  ounces  of  blood 
by  means  of  a  puncture  rapidly  restored  things  to  normal,  and  I 
found  nothing  subsequently  to  give  the  least  support  to  a  diagnosis 
of  fracture.  The  only  "  cerebral  symptom "  she  ever  had  was  the 
noise  with  which  she  came  to  the  Hospital. 

It  is  important  not  to  be  deceived  by  congenital  peculiarities  in  the 
shape  of  the  skull,  such  as  a  deep  hollow  in  the  occipital  bone,  or  by 
the  presence  of  Wormian  bones,  by  syphilitic  ulceration,  or  by  depres- 
sions due  to  former  injuries. 

There  are  some  people  to  whom  accidents  are  doled  out  by  Fate 
with  exceptional  abundance.  Thus,  I  have  seen  a  man  who  sustained 
a  fractured  skull  twice  within  a  year,  in  attempts,  as  he  said,  to 
"preserve  the  peace"  in  a  public  house.  He  at  once  explained  that 
a  depression  found  on  examination  dated  back  to  a  similar  incident, 
ten  years  before. 

A  case  is  reported  of  a  patient  who  fell  from  a  great  height,  and 
the  surgeon  wished  to  explore  over  a  depression.  But  the  patient 
recovered  consciousness  and  explained,  with  just  apprehension,  that 
the  depression  had  been  present  since  infancy. 

(3)  Haemorrhage  is  a  much  more  constant,  and  therefore  a  more 
significant  symptom.  It  may  indeed  be  the  only  evidence  of  a 
fractured  base.  After  any  head  injury,  immediate  inquiry  should  be 
made  for  bleeding  from  the  ear,  mouth,  or  nose. 

In  bleeding  from  the  ear,  it  is  necessary  to  be  sure  that  the  blood 
does  not  originate  from  the  auditory  canal.  If  there  be  but  little 
blood  in  the  canal,  it  may  have  been  caused  merely  by  a  ruptured 
tvmpanic  membrane,  which  can  occur  without  a  fractured  base- 
More  profuse  or  persistent  bleeding,  however,  points  with  great 
probability  to  a  bone  injury,  which  indicates  a  fractured  base,  unless 
the  external  auditory  passage  has  itself  been  severely  wounded. 

The  auditory  canal  has  in  rare  cases  been  injured  by  the  pressuie 
of  an  anterior  displacement  of  the  lower  jaw,  consequent  upon  a  blow. 

Haemorrhage  from  the  nose  and  month  is  only  significant  when  the 
injurv  has  not  directly  involved  the  face.  If  such  injury  can  be 
excluded,  it  points  to  a  fissure  in  the  ethmoid,  sphenoid,  or  anterior 
part  of  the  basilar  process  of  the  occipital  bone.  Exceptionally,  the 
blood  might  come  from  the  Eustachian  tube. 


4  SURGICAL    DISEASES    OF   THE    HEAD 

Diagnostic  importance  attaches  to  subcutaneous  effusions  of  blood, 
as  well  as  to  its  immediate  escape  externally.  Their  situation  and 
their  mode  of  onset  are  both  significant.  They  usually  appear  in  the 
region  of  the  orbit  and  mastoid  process.  They  do  not  appear  directly 
after  the  injury,  as  do  effusions  from  contusion.  It  requires  some  few 
hours  for  the  blood  to  reach  the  superficial  tissues;  occasionally  it 
takes  a  few  days.  We  must  guard  against  diagnosing  every  "black 
eye  "  as  a  fractured  base.  The  possibility  of  the  face  having  been 
involved  in  the  injury  must  always  be  considered  ;  the  patient  may 
have  fallen  on  his  face  in  addition  to  the  primary  accident.  But  in 
the  absence  of  such  a  cause,  we  may  definitely  conclude  that  there 
is  an  orbital  fracture,  generally  on  the  roof,  when  close  observation 
reveals  a  gradual  protrusion  of  the  eyeball,  a  bluish  discoloration  of 
the  eyelids  and  hsemorrhagic  infiltration  of  the  eyelids — signs  all 
pointing  to  bleeding  within  the  fatty  and  cellular  tissue  of  the  orbit. 
If  an  effusion  of  blood  appears  behind  the  ear  a  day  or  two  after  the 
injury,  we  may  conclude  that  the  fracture  is  either  in  the  middle  or 
posterior  cranial  fossa.  If  the  patient  has  not  come  under  observation 
until  the  second  or  third  day,  information  as  to  the  onset  of  the 
ecchymoses,  at  any  rate  the  most  striking  ones  in  the  lid  and  con- 
junctivae, must  be  obtained  from  the  friends. 

A  mistake  might  easily  have  arisen  in  the  following  circumstances. 
A  young  man,  who  had  been  run  over  by  a  cart,  was  brought  into 
hospital  wdth  subconjunctival  ecchymoses.  A  superficial  examina- 
tion suggested  a  fractured  base,  but  he  had  numerous  punctiform 
haemorrhages  over  his  face,  neck,  and  upper  portion  of  the  chest.  It 
was  evidently  a  case  of  congestive  JiceniorrJmges,  due  to  compression 
of  the  thorax.  Some  slight  cerebral  symptoms  followed,  which 
indicated  that  the  effects  of  the  congestion  had  also  been  felt  within 
the  skull.     Several  cases  of  this  kind  have  recently  been  recorded. 

(4)  After  cessation  of  the  haemorrhage,  clear  fluid  may  escape  fro:n 
the  nose  or  ear.  If  this  liquid  contain  little  albumin  and  much 
sodium  chloride  it  is  cerebrospinal  fluid,  and  this  affords  an  additional 
aid  to  diagnosis,  which  is  still  further  confirmed  by  the  escape  of 
brain  substance.  Fortunately,  it  is  not  very  often  that  this  latter  is 
mistaken  for  "  pus  "  by  a  zealous  practitioner. 

(2)  INDIRECT  SYMPTOMS. 

The  direct  symptoms  of  fracture  are  frequently  complicated  by 
secondary  injuries,  which  require  careful  attention  from  the  point 
of  view  of  diagnosis  and  of  prognosis.  These  complications  concern 
the  cranial  nerves,  and  in  the  section  treating  of  cerebral  localization 
we  shall  discuss  the  differential  diagnosis  from  central  palsies 
(figs.  6,  8,  9,  10). 


FRACTURES    OF    THE    SKULL  5 

Facial  paralysis  is  the  commonest  of  these  lesions. 

The  ocular  muscles  are  sometimes  involved,  principally  through  the 
sixlli  nerve,  but  also,  occasionallv,  through  the  ////;'(/  nerve. 

The  nature  of  the  nerve  lesion  can  be  inferred  from  the  time  of 
onset  of  these  paralyses  and  from  their  severity.  If  the  paralysis 
supervenes  immediately  on  the  injury  and  is  complete,  it  is  obvious 
that  the  nerve  must  be  crushed  or  torn  at  its  point  of  exit  from  the 
pons  or  medulla.  If  its  onset  is  delayed  for  some  hours  it  suggests 
compression  by  haemorrhage  ;  if  delayed  for  some  days  the  possibility 
of  infective  neuritis  may  be  entertained,  in  the  case  of  a  complicated 
fracture.  In  the  two  latter  conditions  the  paralysis  gradually  increases, 
but  it  will  probably  remain  incomplete. 

The  following  case  illustrates  the  care  which  must  be  exercised  in 
the  diagnosis  of  these  secondary  injuries  : — 

A  workman  sustained  a  severe  blow  on  the  top  of  the  head,  against 
a  stone  floor.  A  gradually  increasing  oculomotor  paralysis  of  the 
left  side  appeared  on  the  second  day.  Even  if  the  patient  had  not 
been  insured  against  accidents,  one  would  have  thought  of  the 
connection  between  the  injury  and  the  paralysis.  But  subsequent 
detailed  examination  showed  that,  not  only  were  all  the  external 
muscles  of  the  left  eye  paralysed,  but  there  was  loss  of  pupil  reflexes 
in  both  eyes.  The  site  of  the  lesion  must,  therefore,  have  been  in  the 
region  of  the  nucleus.  Inquiries  made  of  the  ophthalmic  surgeon, 
whom  the  patient  had  consulted  a  year  previously  for  a  slight  accident, 
elicited  the  fact  that  already  at  that  time  he  had  no  pupil  reflexes. 
But  no  evidence  of  syphilis  could  then  be  ascertained.  The  left-sided 
ocular  paralysis  improved  under  mercurial  treatment,  which  was 
undertaken  by  way  of  experiment,  but  right-sided  paralytic  symptoms 
developed  subsequently.  The  injury,  therefore,  came  at  an  unpro- 
pitious  moment,  but  it  evidently  was  not  the  sole  cause  of  the  trouble. 
I  saw  the  patient  again  a  few  years  later,  and  on  this  occasion  also 
for  a  slight  injury  to  the  skull.  He  had  constant  double  vision,  and 
Wassermann's  reaction  was  positive. 

Injuries  of  the  optic  nerves  frequently  occur  with  a  fractured  base. 
As  a  rule,  optic  atrophy  appears  after  a  little  time.  Sometimes  the 
nerve  is  only  crushed,  so  that  the  blindness  is  not  complete  :  but  the 
prospect  of  recovery  is  only  small,  because  the  optic  nerve  does  not 
undergo  regeneration  like  a  peripheral  nerve. 

Deafness  results,  either  from  damage  to  the  auditory  nerve,  or  from 
injury  or  concussion  of  the  labyrinth.  The  symptoms  of  the  latter 
are  noises  in  the  ear,  giddiness,  and  nausea;  but  the  latter  must  not 
be  confused  with  the  nausea  caused  by  cerebral  pressure.  Labyrinthine 
concussion  can  occur  independently  of  bone  injury,  so  that  a  diagnosis 
of  fractured  base  cannot  be  made  from  this  condition  alone. 

After  recognizing  the  presence  of  a  fracture  of  the  skull  by  means 
of  the  previously  described  symptoms,  it  is  our  duty  to  determine  its 
course  and  direction. 


6.  SURGICAL   DISEASES   OF   THE    HEAD 

Assistance  is  afforded  for  this  purpose  by  the  visible  objective  signs, 
and  by  the  position  of  appHcation  of  the  force,  if  this  is  ascertained 
from  the  history  or  by  the  site  of  injury  on  the  soft  tissues.  The  skull 
is  bent  at  the  point  whereon  the  blow  is  dealt ;  if  the  force  is  limited 
in  area  the  bone  breaks  concentrically  and  a  perforated  fracture  is 
produced.  Thence,  cracks  radiate  towards  the  opposite  pole,  i.e., 
generally  towards  the  base.  These  constitute  the  split  fractures. 
Sometimes  these  cracks  start  at  the  base  of  the  skull,  because  this  is 
its  weakest  section,  and  run  towards  the  site  of  the  blow  ;  but  occa- 
sionally they  fail  to  reach  it.  This  explains  why  so  many  hssures  are 
limited  to  the  base.  Coininiiintecl  fractures  are  always  surrounded  by 
fissures,  produced  by  bending  and  splitting.  Thoma  simplifies  this 
scheme  still  more,  and  includes  both  forms  under  the  term  "  deforuiity 
fractures  "  (Deforniatiousbruche),  due  to  the  abnormal  reaction  of  the 
bone  to  traction  and  pressure. 


Fig.  I.  — (After  Kocher.)  a  =;  Site  of 
application  of  blow  ;  d  and  c  =  fissures  pro- 
duced. 


Fig.  2. — (After  Kocher.)  d  and  e  =  Basal 
portion  of  fissures  ;  dd  —  separate  contrecoup 
fractures  of  orbital  roof  ;  e  —  effusion  on 
tegmen  tympani. 


So-called  contrecoup  fractures  are  full  of  interest,  and  have  given 
rise  to  much  discussion,  but  they  must  be  clearly  distinguished  from 
the  split  fissures  of  the  base,  just  described.  The  existence  of  these 
fractures  is  doubted  by  some  authorities. 

As  the  skull  is  not  a  rigid  structure,  but  of  an  elastic  nature  and 
subject  to  change  in  shape,  a  portion  of  the  actual  force  of  every  blow 
which  it  sustains  is  received  by  the  brain,  and  is  transmitted  through 
it  to  the  opposite  pole.  The  force  is  checked  at  this  spot,  and  the 
brain  sustains  a  "  contrecoup,"  causing  more  or  less  contusion — a 
contrecoup  contusion.  If  the  bone  is  very  thin  at  this  spot  (orbital 
roof,  possibly  also  the  tegmen  tympani)  it  may  break  under  the  force 


\ 


INJURIES   OF   THE   BRAIN  7 

of  the  cranial  impulse,  or  even  be  completely  pressed  out  of  the  skull 
(contrecoup  fracture).  These  fractures  at  the  opposite  pole,  caused  by 
the  continuation  of  the  force  within  the  cerebral  substance,  are  quite 
independent  of  the  fractures  at  the  base  produced  by  bending  and 
splitting,  and  which  are  due  to  direct  damage  to  the  skull  cap.  The 
accompanying  figures  (i  and  2),  clearly  illustrate  these  varieties  of 
fracture.  They  represent  a  case  which  I  had  the  opportunity  of 
observing  while  acting  as  assistant. 

Similarly  the  force  exerted,  laterally,  by  a  projectile  shot  through 
the  skull,  from  temple  to  temple,  may  result  in  pressing  the  orbital 
roofs  outwards,  i.e.,  into  the  orbit. 

Attention  to  these  points,  and  to  the  observations  made  on  the 
patient,  will  facilitate  an  approximate  diagnosis  of  the  direction  of  the 
fissures,  and  particularly  the  fossa  which  they  traverse.  A  confident 
diagnosis  of  contrecoup  fracture  can  only  be  made  on  the  exposed 
skull,  because  clinically  we  cannot  exclude  the  possibility  of  an 
ordinary  split  fissure  having  involved  the  orbital  roof. 


CHAPTER  II. 
INJURIES  OF  THE  BRAIN. 

As  we  have  already  remarked,  the  treatment  of  fractured  skull  is 
determined  by  the  injury  to  the  brain,  and  not  to  the  bone.  For  this 
reason  our  main  attention  must  be  devoted  to  it.  Injuries  to  the 
brain  may  be  divided  into  three  classes  :  (i)  Concussion  ;  (2)  com- 
pression by  hoiinorrhage  ;  (3)  contusion.  It  is  useful  to  ascribe  a 
special  clinical  picture  to  each  variety;  but  in  practice  the  differ- 
entiation is  not  very  clear,  and  the  different  forms  tend  to  coalesce. 
But  individual  features  of  each  class  can  be  recognized  with  more 
or  less  certainty,  and  separated  fiom  each  other.  An  example  will 
make  this  clear  : — 

A  young  stoker,  w^ho  fell  off  his  engine,  was  picked  up  somewhat 
stunned;  he  remounted,  and  after  the  stupefaction  had  passed  off  he 
became  very  excited.  Vomiting,  headache,  and  retardation  of  the 
pulse  appeared  in  two  hours,  and  after  another  couple  of  hours  had 
passed  he  was  completely  unconscious.  Examination  showed  that 
the  left  temporal  bone  was  involved.  On  trephining,  it  was  found 
that  an  extradural  and  an  intradural  haematoma  existed  under  the 
fractured  bone.  A  second  trephining,  the  next  day,  revealed  a  right- 
sided    intradural    haemorrhage.      On    the    day   after    the    injury,    the 


8  SURGICAL   DISEASES   OF   THE    HEAD 

temperature  rose  to  104°  F.,  and  the  pulse  became  very  rapid,  so  that 
the  prognosis  was  obviously  bad.     Death  took  place  on  the  third  day. 

This  case  permitted  the  formation  of  an  accurate  diagnosis  step 
by  step  during  life. 

The  stunning  which  came  on  immediately  after  the  fall  indicated 
concussion.  The  brief  interval  of  freedom  which  preceded  the  severe 
symptoms  of  pulse  retardation  and  unconsciousness  pointed  to  an 
increasing  cerebral  pressnre,  caused  by  the  JuvinorrJiage,  which  was 
revealed  at  the  operation.  As  the  trephining  which  was  done  immedi- 
ately, on  the  site  of  the  injury,  did  not  yield  complete  relief,  it  was 
obvious  that  there  must  be  either  another  h?ematoma  or  a  contusion 
of  the  brain  or  both  together.  The  slow  pulse  becoming  so  rapid 
pointed  to  the  probability  of  an  increase  in  cerebral  pressure  through 
a  second  hasmatoma,  which  was  found  when  the  contrecoup  area  was 
trephined.  The  simultaneous  rise  of  temperature  led  to  the  diagnosis 
of  cerebral  conhisiou,  which  was  also  verified  at  the  post-mortem. 
There  was  no  meningitis  present,  so  that  the  pyrexia  could  not  be 
attributed  to  this  cause. 

This  is  not  the  place  to  discuss  the  varying  views  which  are 
held  concerning  cerebral  pressure,  and  the  numerous  explanations 
which  have  been  offered  for  so-called  cerebral  concussion.  Fortu- 
nately, the  careful  clinical  observation  of  the  injured  affords  us 
sufficient  indications  for  treatment,  although  we  may  not  be  able  to 
explain  physiologically  every  individual  incident  in  the  case. 

Before  we  ascribe  individual  symptoms,  especially  vomiting,  to  a 
cerebral  origin,  we  must  assure  ourselves  that  there  is  no  other  injury 
in  addition  to  the  fractured  skull,  as  for  instance  an  abdominal  lesion. 
A  young  man,  with  a  fractured  skull,  began  to  vomit  on  the  second 
day,  and  this  was  naturally  regarded  as  a  cerebral  symptom. 
Examination,  however,  showed  that  there  was  effusio4i  jn  the 
abdomen,  and  laparotomy  revealed  a  rupture  in  the  hilus  of  th-e'«pleen. 
Finally  it  must  be  remembered  that  cerebral  symptoniS'^'Such  as 
vomiting  and  stupor,  may  supervene  after  any  severe  injury,  especially 
fractured  limbs.  These  symptoms  are  due  to  fat  emboli,  and  they  are 
associated  with  abundant  fat  in  the  urine,  a  iiiarked  acceleration  of  the 
pulse,  and  probably  bloody  sputum. 


(i)  CONCUSSION  OF  THE  BRAIN. 

We  begin  with  the  mildest  degree  of  brain  injury,  the  so-called 
concussion  of  the  brain.  It  must  be  clearly  understood  that  this 
term  as  usually  applied,  is  a  general  term,  embracing  all  the  milder 
forms  of  brain  injury.  A  mild,  rapidly  evanescent  cerebral  pressure 
is  also  spoken  of  as  concussion  of  the  brain.  "  Concussion  "  is  also 
a  very  comforting  diagnosis  when  an  indefinite  contusion  is  sustained^ 
especially  on  a  part  of  the  cortical  area,  whose  function  is  unknown. 


INJURIES   OF   THE   BRAIN  9 

It  is  very  convenient  to  have  such  a  wholesale  term,  and  the  in- 
adequacy of  the  diagnostic  methods  available,  when  an  accident  has 
just  occurred,  compels  the  practitioner  to  resort  to  this  term,  if  he 
does  not  wish  to  acknowledge  the  impossibility  of  making  an  im- 
mediate diagnosis.  But  in  truth,  the  term  "  concussion  of  the  brain," 
is  of  most  use  to  the  journalist,  who  regards  it  as  part  of  his  profes- 
sional duties  to  provide  his  readers  with  a  ready-made  diagnosis. 

We  will,  for  the  present,  put  aside  the  cases  due  to  pressure  on  the 
brain,  or  to  brain  contusion,  and  consider  those  which  may  be 
attributed  to  a  transient  functional  disturbance,  or,  to  be  more  precise, 
a  vascular  disturbance.  These  circulatory  disorders  have  only  two 
absolutely  diagnostic  signs  ;  one  is  the  fact  that  they  begin  imme- 
diately after  the  accident,  and  the  other  is  their  brief  duration.  The 
very  definition  of  the  term  concussion  demands  that  its  onset  should, 
as  a  sine  qua  11011,  follow  forthwith  upon  the  injury.  Any  interval 
before  its  appearance  puts  pure  concussion  out  of  the  question.  This 
diagnostic  point  is  available  at  once  ;  the  other,  the  brief  duration 
of  the  symptoms,  can  only  be  invoked  later  on,  in  support  of  the 
diagnosis. 

The  course  of  a  case  of  concussion  varies.  The  functions  of  the 
brain  may  return  to  the  normal  within  a  few  minutes,  or  at  most 
within  a  few  hours.  If  the  circulatory  disturbance  has  been  very 
severe,  death  may  ensue  ;  or  indications  of  gradually  increasing  brain- 
pressure  or  of  brain  contusion  may  supervene  on  the  clinical  picture 
of  the  concussion. 

We  have  not  yet  discussed  the  condition  which  obtains  between 
the  sudden  onset  of  the  symptoms  and  their  early  decline,  i.e.,  the 
actual  sviiiptoms  of  concussion.  There  is  hardly  any  single  so-called 
"general  symptom"  which  has  been  omitted  from  the  descriptions 
of  concussion.  These  include'  retardation  and  acceleration  of  pulse 
and  respiration,  headache,  vomiting,  loss  of  consciousness  deepening 
to  coma,  excitement,  pallor,  &c.  Order  can  best  be  introduced  into 
this  chaos  by  adopting  Kocher's  view  that  concussion  is,  in  a  limited 
sense,  an  expression  of  a  sudden  .  rise  in  cerebral  pressure.  The 
pressure  curve  in  concussion  would  resemble  a  section  from  the  curve 
of  a  slowly  rising  cerebral  pressure,  read  backwards,  descending  from 
the  severe  to  the  slight  symptoms.  It  depends,  therefore,  entirely  on 
the  stage  in  which  we  find  the  patient,  whether  there  be  signs  of 
paralysis  or  of  irritability,  of  pulse  retardation  or  acceleration.  The 
symptoms  also  vary  from  case  to  case,  in  accordance  with  the  severity 
with  which  different  parts  of  the  brain  are  affected.  If  the  medulla 
oblongata  suffers  most,  the  pulse  and  respiratory  symptoms  will 
predominate.  Disturbance  of  consciousness  will  be  most  in  evidence 
if  the  main  stress  has  fallen  on  the  cortex. 


10  SURGICAL   DISEASES   OF   THE    HEAD 

The  following  maxim  will  epitomize  the  diagnosis  : — 
Any  cerebral  symptoms  manifested  by  a  patient  immediatelv  after  an 
injurx  to  the  sluill — eitlier  of  unconsciousness,  of  disturbance  in  the 
nu'dulla,  of  irritability  or  paralysis — point  to  his  suffering  from  "  con- 
cussion of  the  brain."  ]Ve  cannot  tell  ivhether  there  be  anx  further 
mischief,  for  ivhich  zee  must  aivait  subsequent  developments.  Such  a 
statement  will  save  both  ourselves  and  the  relatives  from  being  consoled 
with  a  "simple  concussion,"  while  the  patient  shortly  succumbs  to 
pressure  on  the  brain.  The  "  further  mischief "  refers,  as  already 
stated,  to  brain  contusion  on  the  one  hand,  and  meningeal  haemor- 
rhage, with  gradually  increasing  pressure,  on  the  other  hand. 


(2)  CONTUSION  OF  THE  BRAIN. 

We  will  now  proceed  to  consider  contusion  of  the  brain.  This 
consists  of  mechanical  damage  to  the  nerve  tissue.  This  clearly 
differentiates  it  from  concussion,  which  is  a  circulatory  disturbance. 
But  nevertheless  there  are  numerous  intermediate  forms  in  which  it 
is  difficult  to  decide  between  the  two,  even  at  the  autopsy,  let  alone 
during  life.  Experiment  and  histological  research  have  shown  that  a 
severe  blow  causes,  not  only  circulatory  disturbance,  but  also 
mechanical  damage  to  the  nerve  elements  and  interference  with  their 
mutual  connections.  Although  no  naked  eye  changes  be  produced, 
the  severest  functional  disorders  may  follow,  and  even  death.  The 
difference  between  these  changes  and  foci  of  contusion  visible  at  an 
autopsy  is  only  one  of  degree.  There  is  a  whole  series  of  connecting 
links  between  an  obvious  contusion  and  the  microscopic  changes 
which  are  present  in  what  is  clinically  a  simple  concussion. 

How  can  we  clinically  diagnose  a  contusion  ?  As  in  the  case  of 
concussion  there  is  immediate  onset  of  the  symptoms  after  the  injury. 
But  the  principal  clinical  difference  between  the  two  concerns  the 
matter  of  duration.  Again,  in  contusion  focal  symptoms  predominate; 
there  are  signs  of  irritation  or  paralysis  in  cortical  areas  whose 
functions  we  know,  whereas  in  pure  concussion  the  "  general 
symptoms"  are  more  evident.  But  too  much  importance  is  generally 
attached  to  this  distinction.  There  are  many  cortical  areas  whose 
functions  we  do  not  yet  know,  so  that  we  cannot  ascertain  clinically 
whether  they  have  been  damaged.  When  a  patient  is  unconscious  it 
is  not  possible  to  test  whether  all  the  areas  are  functional,  as  for 
instance  the  occipital  cortex.  Some  of  the  slighter  and  of  the 
moderately  severe  symptoms  must  really,  as  a  rule,  be  referred  to  the 
accompanying  concussion.  A  definite  contusion  of  the  medulla 
produces  so  rapid  a  death  by  paralysis  of  the  vital  centres,  that  no 
time  is  allowed  for  diafjnostic  reflections.      But  there  is  alwavs  one 


INJURIES    OF   THE    BRAIN  11 

symptom  which  soon  leads  to  an  accurate  diagnosis,  and  also  permits 
the  formation  of  a  corresponding  prognosis.  This  consists  of  a  rise 
in  teinpemfitre,  no  matter  whether  we  regard  it  as  a  sign  of  irritation 
of  the  corpus  striatum  or  not.  It  is  quite  certain  that  a  persistent  and 
rising  pyrexia  coming  on  a  day  or  two  after  the  injury  must  be 
attributed  to  some  form  of  brain  contusion.  Some  fever  is  frequently 
present  in  cases  of  haematoma  ;  but  a  temperature  of  102°  F.  and  above 
is  very  suspicious  of  contusion,  even  if  a  haematoma  exists  at  the  same 
time.  This  temperature  does  not  presuppose  an  extensive  contusion. 
Indeed  the  post-mortem  appearances  were  almost  negative  in  most  of 
the  cases  wherein  this  fever  was  present;  and  we  must,  therefore, 
assume  that  microscopic  damage  of  the  brain  tissue  had  occurred, 
death  having  followed  too  rapidly  for  the  development  of  visible  foci 
of  degeneration.  The  diagnosis  is  easier  if  limited  paralyses,  and 
especially  if  limited  spasms,  remain  after  the  symptoms  of  concussion 
have  passed  away.  The  diagnosis  is  equally  easy  if  such  symptoms  come 
on  day  by  day,  while  excitement  and  delirium  continue,  without  pre- 
senting the  features  of  brain  pressure,  to  be  subsequently  described. 

A  transitory  rise  of  temperature,  due  to  a  transitory  disturbance 
of  the  cerebral  circulation,  i.e.,  a  pure  concussion  if  possible,  has 
apparently  been  proved  clinically.  We  are,  however,  now  referring 
to  a  persistent  rise  in  temperature,  which,  moreover,  tends  to  increase 
as  the  case  progresses. 

The  following  conclusion  may  be  drawji  for  the  diagnosis  of 
contusion  of  the  brain  : — 

A  patient  wlio,  iuiuiediatclx  after  an  injury  to  the  stiuU,  manifests 
brain  symptoms,  ivtiicli  persist  fot  a  wliole  day,  and  ichicJi  do  not  fit  in 
with  tlie  signs  of  a  gradnallv  increasing  cerebral  pressure,  has  sustained 
a  contusion  of  tlie  braiu,  in  ttie  widest  sense  of  ttie  term.  Tliis  view  is 
supported  by  tlie  presence  of  irritative  or  localizing  symptoms,  arising 
from  cortical  areas  of  ascertained  function.  It  is  definitelv  confirmed  by 
a  persistent  rise  in  temperature,  which  cannot  be  explained  by  infection 
from  without. 

We  have  hitherto  maintained  that  the  symptoms  of  contusion 
follow  the  injury  forthwith.  As  a  general  rule  this  is  quite  true,  but 
their  severity  often  increases  gradually,  and  this  might  be  regarded  as 
due  to  pressure  consequent  upon  haemorrhage.  Operation  or  autopsy, 
however,  shows  that  despite  the  presence  of  signs  of  great  pressure 
{failure  of  the  cerebral  pulse  and  flattening  out  of  the  convolutions), 
there  is  no  corresponding  haemorrhage.  We  must,  therefore,  assume 
that  the  contusion  itself  can  lead  to  a  persistent  disturbance  in  the 
circulation  with  a  subsequent  rise  in  pressure.  The  same  thing 
happens  in  the  brain  as  in  a  contused  limb — it  swells,  and  becomes 
too  large  for  the  skull,  even  without  any  extensive  haemorrhage — acute 
tiaumatic  cerebral  congestion. 


12  SURGICAL   DISEASES   OF   THE    HEAD 

(3)   CEREBRAL    PRESSURE    FOLLOWING    HEMORRHAGE. 

The  third  form  of  damage  which  the  brain  suffers  as  a  result  of 
injury  is  the  rise  in  pressure  consequent  upon  haemorrhage.  The 
source  of  the  haemorrhage  is  a  torn  blood-vessel,  either  inside  or 
outside  the  dura.  As  bleeding  to  the  extent  of  nearly  two  ounces  can 
be  tolerated  without  any  serious  disturbance,  it  follows  that  the  clinical 
signs  of  pressure  will  not  appear  at  once,  but  only  when  the  extrava- 
sation has  reached  a  certain  amount.  An  interval  of  varied  length 
will  intervene  between  this  point  of  time  and  the  moment  of  the 
accident.  During  this  interval  we  may  not  recognize  anything  wrong 
with  the  patient,  or  may  regard  him  merely  as  suffering  from  a  rapidly 
recovering  concussion.  The  duration  of  this  "  free  interval  "  varies 
with  the  rate  at  which  the  blood  pours  out  of  the  torn  vessel.  It 
may  last  from  a  quarter-of-an-hour  to  several  days — even  a  week  or 
more.  The  symptoms  consist  partly  of  irritative,  and  especially  of 
paralytic  phenomena,  dependent  upon  the  part  of  the  cortex  pressed 
upon — local  cerebral  pressure — and  also  partly  of  manifestations  of 
general  cerebral  pressure.  The  former  obviously  vary  with  the  situation 
of  the  haematoma ;  but  the  latter  usually  run  a  regular  course,  in  which 
the  following  stages  can  be  distinguished  : — 

{a)  Stage  of  cominencing  cerebral  pressure,  marked  by  signs  of 
irritability,  especially  headache,  psychical  excitement  and  retardation 
of  pulse. 

(b)  Stage  of  completed  rise  of  pressure,  marked  by  a  mixture  of 
irritative  and  paralytic  signs,  and  finally, 

(r)  The  paralytic  stage  proper,  when  irritability  has  disappeared, 
and  coma,  Cheyne-Stokes  breathing,  and  a  rapid  irregular  pulse  have 
supervened. 

We  may  now  briefly  refer  to  the  diagnostic  value  of  the  various 
so-called  classical  symptoms  of  cerebral  pressure. 

(i)  Headache. — A  continuous  headache  is  the  first  symptom  com- 
plained of  when  the  cerebral  pressure  is  beginning  to  rise.  There  are 
many  cases  of  injury  to  the  skull  whereni  this  is,  and  remains,  the 
only  sign  of  a  slight  haemorrhage. 

(2)  Vomiting,  as  in  all  forms  of  cerebral  pressure,  is  an  important 
initial  symptom.  It  is  also  present  in  injuries  to  the  labyrinth,  and 
it  may  be  a  transitory  accompaniment  of  concussion.  It  is  only  of 
diagnostic  value  when,  after  a  free  interval,  it  heralds  the  onset  of  the 
other  pressure  symptoms. 

(3)  TJie  state  of  the  consciousness  is  of  greater  significance.  The 
sensorium  is  not  at  first  affected  ;  and  if  the  haemorrhage  be  slight, 
it  may  remain  unaffected.  But  as  the  pressure  increases,  excitement 
and  even  delirinm  come  on ;  when  the  pressure  has  risen  high  the 


INJURIES    OF   THE    BRAIN 


13 


signs  of  irritability  abate,  and  the  patient  becomes  sleepy,  lapsing 
eventually  into  a  persistent  stupor,  which  in  severe  cases  changes  with 
terrible  rapidity  into  complete  coma. 

(4)  Congestion  of  the  Disc. — ^Although  this  is  the  rule  in  pressure 
due  to  cerebral  tumour,  it  is  rarely  met  with  when  the  pressure  is  due 
to  haemorrhage.  It  is  an  early  symptom,  which  has  often  vanished 
by  the  time  the  patient  is  examined  ophthalmoscopically. 

(5)  Tlie  pnpils  are  rather  contracted  at  first,  but  they  react  to  light. 
One-sided  dilatation,  with  absence  of  the  light  reflex,  indicates  severe 
damage — pronounced  pressure — of  the  corresponding  side.  Dilatation 
of  both  pupils  is  a  sign  of  the  paralytic  stage, 

(6)  The  Pressnre  Pulse. — This  term  is  used  for  the  full,  tense,  and 
slow  pulse  of  the  early  stage,  although  the  paralytic  pulse  of  the  final 
stage  is  also  a  pressure  pulse.  The  presence  of  this  slowing  of  the 
pulse  is  of  the  greatest  diagnostic  value.  But  it  may  be  absent,  or  at 
any  rate  concealed,  in  cases  of  quite  definite  cerebral  pressure.  There 
are  two  possible  reasons  for  this.  Slowing  of  the  pulse  is,  after  all, 
a  relative  condition  ;  it  must  be  estimated  in  relation  with  the  other 
symptoms  presented  by  the  patient.  For  instance,  if  there  is  fever, 
a  pulse  of  70  or  80  will  actually  be  slow,  and  represent  a  pressure 
pulse.  The  same  consideration  holds  good,  as  Kocher  remarks,  when 
the  breathing,  for  one  reason  or  another,  becomes  rapid  or  deep. 
Finally,  it  must  not  be  forgotten  that  a  very  high  degree  of  local 
pressure  may  exist  in  an  exposed  skull  fracture,  without  the  develop- 
ment of  any  general  brain  pressure. 

But,  apart  from  this,  the  pulse  may  sometimes  remain  normal  for 
quite  a  long  time  in  cases  of  severe  brain  pressure,  between  the  initial 
and  the  paralytic  stages.  Probably  the  presence  of  contusions  may 
account  for  this. 

Irregnlariiy  is  not  a  necessary  concomitant  of  the  pressure  pulse. 
It  first  appears  when  the  patient  approaches  the  paralytic  stage.  The 
pulse  is  first  slow  but  regular,  then  slow  and  irregular,  and  finally 
rapid  and  irregular.  This  last  stage  is  sometimes  ushered  in  by  a 
transition  stage,  wherein  the  pulse  rapidly  changes  from  slow  to  fast 
and  vice  versa.  This  is  a  matter  of  great  importance,  when  the 
diagnosis  rests  between  pressure  and  contusion. 

(7)  Respiratory  Changes. — The  breathing  is  at  first  hurried,  but,  like  the 
pulse  in  definite  cerebral  pressure,  it  then  becomes  slow;  frequently  it 
becomes  deep,  and,  with  the  further  progress  of  the  case  irregular.  In 
the  paralytic  stage,  Cheyne-Stokes  breathing  appears. 

(8)  The  local  pressure  symptonis  begin  with  indications  of  irritability, 
viz.,  convulsions,  contractures,  increased  reflexes,  and  later  on  paralysis 
of  the  centre  exposed  to  the  pressure.  There  will  be  mono-  and 
hemispasms,  mono-  and  hemiplegia,  according  to  the  situation  and 
extent  of  the  haematoma.  Conjugate  deviation  of  the  eyes  towards 
the  healthy  side  in  the  stage  of  irritability,  or  towards  the  injured  side 


I^  SURGICAL   DISEASES   OF   THE    HEAD 

in  paralysis  of  the  cortical  centre,  is  especially  significant.  ("In 
irritation  of  the  centre  the  patient  looks  away  from  this  lesion;  in 
paralysis  he  looks  towards  it.")  If  the  hasmatoma  is  in  the  region  of 
Broca's  convolution,  a  more  or  less  definite  cortical  motor  aphasia 
will  develop.  If  it  is  situated  over  the  left  temporal  lobe,  sensory 
aphasia  will  be  found  ;  if  in  the  occipital  region,  there  will  be 
hemianopia,  i.e.,  blindness  of  the  two  halves  of  the  visual  field  of 
opposite  sides.     Further  details  will  be  given  in  Chapter  VI. 

All  the  symptoms  will  vary  very  considerably  according  to  the 
situation  and  extent  of  the  haematoma,  and  according  to  its  rapid  or 
slow  formation.  As  the  various  centres  differ  in  their  irritability,  it 
will  often  happen  that,  with  the  same  pressure,  one  centre  will  be  in 
a  state  of  irritation,  while  another  is  already  paralysed.  It  will,  there- 
fore, seldom  happen  that  the  symptoms  described  will  be  observed  in 
their  classical  order.  Nevertheless  we  shall  not  overlook  brain 
pressure  from  injury,  if  we  adopt  the  following  summary  of  the 
foregoing  : — 

//  a  patient  has  sustained  an  /injury  to  the  sJiull,  and  then,  after  a 
free  interval  of  very  variable  duration,  or  after  the  cessation  of  initial 
signs  of  concussion,  brain  svniptoins  of  any  kind  supervene,  it  is  probable 
that  there  is  pressure  from  heeinorrhage,  wliether  the  brain  symptoms  be 
focal  or  general.  If  the  svmpioms  increase  we  must  regard  the  case  as 
one  of  brain  pressure,  even  if  the  classical  signs  of  that  condition  are  not 
present  in  a  fnllv  developed  form,  viz.  :  Disturbance  of  conscionsness, 
sloiving  of  pulse  and  respiration,  and  congested  disc. 

As  previously  remarked,  there  are  cases  of  definite  brain  pressure 
after  an  injury,  wherein  there  has  been  no  considerable  haemor- 
rhage at  all.  In  the  absence  of  any  striking  rise  in  temperature, 
pointing  to  contusion,  it  is  sometimes  quite  mipossible  to  be  sure 
of  the  diagnosis. 

If  we  are  convinced  of  the  existence  of  a  haematoma,  our  next  step 
is  to  determine  its  situation.  As  a  rule  we  are  led  to  a  satisfactory 
conclusion  by  clinical  experience,  and  by  taking  into  consideration 
the  position  of  the  injury  and  the  existing  brain  symptoms. 

Experience  shows  that  haemorrhages  arising  from  the  middle 
meningeal  artery  and  situated  between  the  dura  and  the  skull,  have 
a  certain  typical  localization.  Most  frequently  the  bleeding  indicates 
a  rupture  of  the  root  of  the  artery  or  its  anterior  branch,  and  is  situated 
beneath  the  squamous  portion  of  the  temporal  bone.  Less  frequently, 
the  posterior  branch  is  torn,  giving  rise  to  a  haematoma  in  the  parietal 
region.  More  rarely  still,  a  circumscribed  haemorrhage  may  be  found 
over  the  frontal  lobe,  or  in  the  posterior  fossa. 

A  knowledge  of  the  site  of  the  injury  is  important  for  two  reasons, 
because  sometimes  the  haemorrhage  is  immediately  underneath,  and 


INIURIES   OF   THE   BKAIN 


15 


because    there    may    occasionally    be    an    intradural    effusion    from 
contrecoup,  at  the  opposite  pole  of  the  skull. 

We  have  already  seen  how  conlrecoup  fractures  and  corresponding 
brain  contusions  arise.  Fig.  3  represents  the  same  brain  as  figs,  i 
and  2.  Whereas  contrecoup  fractures  are  practically  confined  to  the 
orbital  roofs,  contrecoup  contusions  with  corresponding  haemorrhages 
may  occur  at  any  spot  which  constitutes  the  opposite  pole  of  the 
force  of  the  blow. 

In  the  absence  of  other  symptoms  a  careful  search  must  be  made 
for  wounds  or  bruises  on  the  skin  which  will  indicate  the  site  of  the 
lesion  and  the  probable  situation  of  contrecoup  effects. 

The  existing  brain  symptoms  furnish  the  most  important  guides. 
Aphasia,  monoplegia,  hemiplegia,  perhaps  occasionally  a  hemianopia 
indicate,  at  once,  the  site  of  the 
pressure.  Localized  convulsions 
or  attacks  of  Jacksonian  epilepsy 
will  do  the  same.  Often  enough, 
it  is  necessary  to  employ  all  the 
three  aids  to  establish  an  exact 
diagnosis. 

For  example  :  A  young  man 
was  thrown  off  a  horse,  and  on 
the  following  day  he  showed  sym- 
ptoms, partly  of  contusion  and 
partly  of  brain  pressure.  As  the 
symptoms  increased,  it  was  neces- 
sary to  interfere.  The  skin  was 
abraded  in  the  right  temporal 
region,  and  there  was  a  bruise 
behind  the  right  mastoid  process. 
There  was  paresis  of  the  right 
side  of  the  face  and  the  right  arm, 
and  the  right  thumb  was  spas- 
modically contracted  into  the 
hand.  Conclusion  :  probably  a 
hasmatoma  over  the  site  of  in- 
jury, but  certainly  a  haemorrhage  by  contrecoup  over  the  left  hemi- 
sphere. Both  sides  were  trephined,  and  an  insignificant  hsematoma 
was  found  on  the  right  side  under  the  injured  skull,  while  on  the  left 
side  a  large  intradural  haematoma  existed. 

Can  we  distinguish  whether  the  hcemorrhage  is  extra-  or  intradural  f 
This  question  has  often  been  raised  and  has  been  variously  answered. 
The  following  anatomical  considerations  will  guide  us  :  An  extradural 
haemorrhage  arises  from  injury  to  the  middle  meningeal  artery,  a 
comparatively  large  vessel;  while  bleeding  under  the  dura  arises  from 
injury  of  the  much  smaller  vessels  of  the  pia. 


Fig.  3. —(After  Kocher.)  Contrecoup  con- 
tusions Irom  force  applied  on  convexity  ;  con- 
trecoup fractures  also  produced.  (See  figs. 
I  and  2.) 


l6  SURGICAL   DISEASES   OF   THE    HEAD 

Further,  the  dura  is  much  more  adherent  to  the  skull  than  the  soft 
membranes  of  the  brain.  We  may,  therefore,  draw  the  following 
conclusion  :  Owing  to  the  size  of  the  vessel,  an  extradural  haemor- 
rhage will  develop  more  rapidly  than  an  intradural,  but  owing  to 
the  close  adhesion  of  the  dura  to  the  skull  the  former  will  remain 
more  limited  than  the  latter.  For  the  same  reason  the  focal  symptoms 
of  an  extradural  haemorrhage  will  be  more  definite  than  those  of  the 
intradural  variety.  The  latter  is  often  characterized  by  a  prolonged 
free  interval,  and  by  the  predominance  of  general  pressure  symptoms 
over  those  indicating  disturbance  of  the  motor  area.  A  haematoma 
situated  directly  over  the  cerebral  cortex  is  more  likely  to  produce 
irritation  than  one  with  an  extradural  situation.  Intradural  haemato- 
mata  are  more  often  accompanied  by  contusion,  and  therefore  by  rise 
of  temperature,  than  are  the  extradural.  Haem'atomata  at  the  base  of 
the  skull  are  generally  intradural,  because  the  dura  is  so  closely 
adherent  to  the  bone  in  that  region. 

But  the  favourite  situation  for  large  intradural  haematomata  is  on 
the  convexity,  in  the  neighbourhood  of  the  falx  cerebri.  Even  in  this 
situation  aphasia  may  be  the  only  focal  symptom,  which  comes  on 
eventually.  I  have  seen  this  in  two  cases  which  came  under  observa- 
tion shortly  after  one  another.  The  free  interval  lasted  four  to  six 
weeks,  and  there  were  no  striking  symptoms  of  interference  with  the 
limbs,  despite  a  very  extensive  haematoma  over  the  convexity.  Tliere 
were,  however,  slight  aphasic  disturbances,  which,  at  any  rate,  indicated 
the  side  upon  which  the  haematoma  was. 

Endeavours  have  been  made  to  get  information  from  lumbar 
puncture.  Blood-stained  fluid  justifies  the  diagnosis  of  intradural 
haemorrhage,  but  a  negative  result  does  not  necessarily  mean  an  extra- 
dural haemorrhage.  The  decision  as  between  an  extra-  and  an  intra- 
dural haemorrhage  is,  however,  not  of  much  importance  from  the 
point  of  view  of  treatment.  The  main  question  to  solve  is  whether 
there  be  a  contusion  or  a  haemorrhage,  and  lumbar  puncture  confers 
no  definite  assistance  in  this  direction.  Blood-stained  fluid  may  be 
expected  both  in  contusion  and  in  intradural  haematoma.  An 
exploration  of  the  skull  is  much  more  valuable  in  a  doubtful  case. 
Sometimes  a  drill  hole  opening  will  suffice,  but  it  is  safer  to  make 
an  opening — a  few  millimetres  in  extent — in  order  to  ascertain  with 
certainty  the  condition  of  the  cerebral  membranes  and  the  cortex. 
Sometimes  several  such  openings  will  be  required  before  the  haema- 
toma is  discovered.  But  this  is  a  matter  of  therapeutics  rather  than 
of  diagnosis,  and  should  only  be  undertaken  when  all  preparations 
have  been  made  for  an  extensive  operation.  We  do  not  wish, 
however,  to  imply  that  every  case  of  brain  pressure  from  haemorrhage 
requires  trephining.  Many  intracranial  haemorrhages  —  especially 
intradural — get  absorbed  without  any  interference,  and  we  frequently 
see  the  symptoms  of  an  incipient  pressure  disappear  in  a  few  days. 


ABSCESS,    PACHYMENINGITIS,    CYST,    AND    TUMOUR   OF    BRAIN  17 

But  every  patient  with  signs  of  pressure  ought  to  be  placed  in 
circumstances  wherein  operation  can  be  performed  forthwith  if 
symptoms  increase,  especially  if  any  disturbance  of  consciousness 
occurs.  But  for  this  purpose  it  is  necessary  to  recognize  the  pressure 
symptoms  early,  even  without  any  exploratory  trephining. 

The  sites  of  traumatic  contusions  and  hfemorrhages  are  not  always 
on  the  surface  of  the  brain.  Haemorrhages  have  been  observed  in  the 
medullary  layer  and  in  the  ventricle.  These  deep-seated  injuries  are 
most  liable  to  occur  when  the  concentration  of  the  force,  transmitted 
through  the  brain,  becomes  divided,  or  when  the  force  is  diverted 
from  its  direct  line,  as  happens  in  the  vicinity  of  the  ventricle,  especi- 
ally the  3rd,  and  the  basal  ganglia. 


CHAPTER    III. 

ABSCESS  OF  BRAIN,  H^EMORRHAGIC  PACHY- 
MENINGITIS, CYST  OF  BRAIN,  TUMOUR  OF  BRAIN. 

As  one  of  the  primary  rules  for  the  diagnosis  of  cerebral  abscess 
or  tumour,  the  proposition  must  be  stated  that  occasionally  both  these 
diseases  run  a  long  course  without  a  symptom,  and  then  death  may 
ensue  with  very  few  typical  symptoms,  and  with  such  rapidity  as 
to  cause  dismay,  both  to  the  relatives  and  to  the  medical  attendant. 

A  young  man,  in  perfect  health,  began  to  complain  of  pain  at  the 
back  of  the  head.  The  doctor  regarded  it  as  an  occipital  neuralgia 
of  unknown  origin  ;  treated  the  patient  accordingly  and,  at  his  last 
visit,  declared  that  the  trouble  was  insignificant.  Two  days  later,  that 
is,  ten  days  from  the  onset  of  the  pain,  the  patient  suddenly  fell  ill  and 
died  within  a  few  minutes.  The  autopsy  revealed  a  glio-sarcoma  of 
the  cerebellum,  as  large  as  a  plum. 

With  cerebral  tumours  we  must  include  growths  from  the 
meninges,  the  internal  surface  of  the  skull,  as  well  as  solitary  tubercles 
and  gummata,  because  all  these  diseases  assert  themselves  by  the  same 
symptoms.  These  consist  of  a  combination  of  symptoms  due  to 
general  brain  pressure  with  signs  of  local  displacement  and  destruc- 
tion. These  symptoms  also  apply  to  cerebral  abscesses,  but  the  latter 
are  distinguished  from  tumour-like  formations  by  their  cause,  their 
rapid  progress,  and  occasionally  by  high  temperature. 

The  most  important  symptom,  and  the  one  which  the  patient 
notices  first,  is  Jieadadic.  In  the  early  stages  it  only  comes  on,  in 
2 


iS  SURGICAL    DISEASES    OF   THE    HEAD 

attacks,  and  there  are  long  intervals  of  freedom.  But  its  great 
intensity  should  serve  to  differentiate  it  from  other  ordinary  head- 
aches. Sometimes  there  are  attacks  of  giddiness,  or  epileptifor'in 
seizures,  in  addition  to  the  headache,  before  ever  any  permanent  focal 
symptom  can  be  detected  by  examination.  Occasionally,  the  brain 
pressure  reveals  itself  by  apparently  unprovoked  vomiting,  a  symptom 
recognized  as  one  of  the  early  indications  of  tubercular  meningitis. 
If  the  retina  is  examined,  an  indispensable  proceeding  in  all  cases  of 
severe,  persistent,  or  intermittent  headache,  a  congested  disc  will 
probably  be  already  found  at  this  stage.  This,  of  course,  absolutely 
excludes  the  possibility  of  simple  neurasthenia.  At  first  the  disc  is 
congested  only  on  one  side  in  tumours  of  the  frontal  lobe,  but 
the  congestion  appears  sooner  in  these  tumours  than  in  those  of  the 
motor  area. 

There  is  usually  no  slowing  of  the  pulse  in  cases  of  abscess  or 
tumour;  it  is  only  present  when  symptoms  become  acute. 

It  is  necessary  to  utter  here  a  word  of  warning  which  may  be 
useful  even  to  experts.  Headache,  attacks  of  unprovoked  vomiting, 
and  epileptiform  seizures  may  occur  during  the  course  of  nephritis, 
and  an  albuminuric  retinitis  may  be  confused  with  a  congested  disc. 
An  examination  of  the  urine  should,  therefore,  never  be  neglected 
when  there  are  brain  symptoms  of  unknown  origin  ! 

Although  a  congested  disc  or  optic  neuritis  alojie  must  at  once 
excite  suspicion,  it  does  not  clench  the  diagnosis  of  cerebral  disease, 
because  it  may  also  be  present  after  infectious  diseases,  in  syphilis  and 
lead  poisoning.  In  the  latter  case  the  optic  neuritis  may  be  associated 
with  other  brain  symptoms  of  plumbism  which  would  easily  suggest 
a  diagnosis  of  cerebral  tumour  if  one  were  not  aware  of  the  cause,  and 
the  presence  of  the  blue  line  on  the  gums.  This  possibility  should 
always  be  considered.  Error  may  also  be  caused  by  thrombosis  of 
the  central  veins,  which  occurs  in  arteriosclerotic  or  anaemic  persons. 

A  cerebral  tumour  of  the  central  convolutions,  or  their  proximity, 
gives  rise  usually  to  an  epilepsy  of  the  Jacksonian  type,  consisting 
of  localized  clonic  spasms,  which  eventually  merge  into  generalized 
attacks  as  the  disease  advances.  But  if  the  tumour  is  otherwise 
situated,  the  attacks  may  be  indistinguishable  from  true  epilepsy. 

Having  arrived  at  the  diagnosis  of  a  lesion  which  is  causing 
pressure  on  the  brain,  we  must  distinguish  between  comparatively 
acute  conditions,  like  abscesses  and  hsemorrhages,  and  those  of  more 
gradual  progress  like  guniniata,  tubercles,  tumours  and  cysts. 

(i)  ABSCESS  OF  THE  BRAIN. 

The  principal  argument  in  favour  of  abscess  is  the  comparatively 
rapid  course  of  all  the  symptoms.     The  events  in  tumour  formation. 


ABSCESS,    PACHYMENINGITIS,    CYST,    AND   TUMOUR   OF   BRAIN  IQ 

which  are  spread  over  months  or  years,  are  often  in  the  case  of 
abscesses  crowded  into  a  few  weeks.  But  there  are  many  exceptions. 
Abscesses  which  are  not  very  acute  may  remain  unnoticed  for 
months  or  even  a  whole  year,  if  they  have  developed  a  firm  limiting 
membrane. 

Even  in  these  chronic  cases  the  whole  course  of  the  disease  differs 
from  that  in  tumour.  The  development  of  an  abscess  is  more  irregular 
than  that  of  a  tumour,  as  indicated  by  periods  when  the  whole  con- 
dition becomes  worse  and  is  complicated  by  a  rise  of  temperature.  We 
have  hardly  yet  referred  to  the  latter,  although,  a  priori,  one  would 
expect  that  the  temperature  would  differentiate  an  abscess  from  a 
tumour.  But  this  is  not  by  any  means  the  rule.  In  some  abscesses 
there  is  no  rise  of  temperature  at  all,  or  it  comes  at  the  very  end, 
when  it  is  too  late  for  professional  assistance.  On  the  other  hand, 
there  may  be  an  irregular  temperature,  even  as  high  as  ioo'5°  F.,  in 
cases  of  cerebral  tumour,  and  naturally  also  in  cases  of  solitary 
tubercles.  A  rise  in  temperature  can  only  be  regarded  as  an  aid  in 
the  diagnosis  of  an  abscess  in  the  exceptional  cases  wherein  it 
possesses  the  definite  character  of  a  suppuration  pyrexia — i.e.,  morning 
remissions  with  regular  evening  rises,  or  if  the  aggravation  of  the 
brain  symptoms  is  accompanied  by  very  high  fever.  In  both  these 
cases  we  should  conclude  that  the  fever  points  not  only  to  an  abscess, 
but  also  to  its  extension. 

The  value  of  a  congested  disc  for  differential  diagnosis  consists 
in  its  pointing  to  a  tumour  rather  than  an  abscess. 

Pain  on  percnssing  a  limited  area  on  the  skull  may  be  a  further 
sign  of  abscess,  but  it  is  also  present  in  tumours  and  tubercle,  so 
we  cannot  ascribe  to  it  any  differentiating  value. 

The  chief  factor  in  our  diagnostic  reflections  must  concern  the 
etiology.  An  abscess  of  the  brain  always  has  a  definite  cause,  in  so 
far  as  there  must  be  a  portal  of  infection,  which  can  generally  be 
demonstrated  clinically.  A  tumour,  on  the  other  hand,  has  no  cause 
which  we  can  ascertain,  at  any  rate,  when  it  is  primary.  We  must, 
therefore,  primarily  search  for  the  source  of  an  infection.  If  there  be 
an  open  wound  in  the  skull,  this  is  easv  enough,  but  even  here  the 
abscess  may  supervene  long  after  the  wound  has  healed.  Exceptionally, 
micro-organisms  can  make  their  way  by  metastasis  to  a  contused  area 
of  the  brain. 

On  one  occasion  I  saw  multiple  abscesses  following  contusion  in 
an  old  bronchitic  patient.  These  contained  pure  cultures  of  Frankel's 
pneumococci.  But  an  abscess  of  the  brain  is  more  frequently  the 
sequel  of  non-traumatic  suppuration  in  the  cranial  bones,  the  principal 
example  of  which  is  chronic  suppurative  inflammation  of  the  middle 
ear,  especially  when   this   has  attacked  the  air  spaces  in   the  peh^ous 


20  SURGICAL   DISEASES    OF   THE   HEAD 

portions  of  the  temporal  bone  and  led  to  its  destruction.  Every 
patient  who  has  ear  suppuration,  even  if  his  brain  symptoms  are  not 
very  striking,  must  be  suspected  of  abscess  of  the  brain.  We  shall 
see  in  the  next  chapter  how  this  differs  from  other  complications  of 
otitis. 

Suppuration  in  the  frontal  sinus  must  also  be  taken  into  con- 
sideration, although  this  is  a  less  frequent  cause  of  cerebral  abscess 
than  ear  suppuration. 

If  no  focus  of  suppuration  can  be  found  in  the  skull-cap,  we  must 
look  elsewhere  in  the  body  for  a  source  of  infection.  Suppuration 
in  the  pleura  is  the  most  probable  source  in  this  connection. 

A  young  man,  with  a  tubercular  family  history,  suffered  from  an 
empyema  which  was  at  first  treated  by  Biilau's  drainage.  As  the 
suppuration  did  not  cease,  he  was  transferred  to  the  surgical  ward. 
After  resection  of  several  ribs  the  empyema  was  cured  and  there 
remained  only  a  small  fistula  in  the  scar.  Then  suddenly  brain 
symptoms  appeared,  signs  of  pressure  without  fever  and  without  any 
focal  indication.  The  tubercular  heredity  strongly  suggested  tubercular 
meningitis.  In  a  week's  time  right-sided  hemiplegia  suddenly  super- 
vened, followed  by  death  a  few  hours  later.  Autopsy  revealed  a  large 
abscess  of  the  brain  in  the  left  precuneus,  behind  the  falx  cerebri. 

There  is  no  doubt  that  this  abscess  formed  while  the  pus  in  the 
pleural  cavity  was  under  pressure,  i.e.,  before  the  resection  of  the  ribs, 
and  probably  before  the  drainage.  It  developed  quietly  without  focal 
symptoms  because  it  was  not  situated  directly  in  the  motor  area. 

Suppuration  of  the  gall-bladder  can  also  be  the  source  of  infection 
for  an  abscess  of  the  brain. 

Finally,  actinomycosis  of  the  jaw  has  frequently  led  to  abscess  of 
the  brain,  either  by  metastasis  or  extension. 

Directions  for  the  localization  of  abscesses  are  given  below  in 
connection  with  tumours,  and  also  in  Chapter  VI. 

(2)  H.^MORRHAGIC  PACHYMENINGITIS. 

Assuming  that  we  have  excluded  the  presence  of  a  chronic  abscess 
of  the  brain,  principally  because  we  cannot  fix  upon  a  likely  source, 
we  still  have  other  conditions  which  may  explain  symptoms  with 
which  we  are  dealing.  These  are  :  (i)  HcemorrJiagic  pacliyuieniiigitis  ; 
(2)   traumatic  softening,  or  traumatic  brain  cysts. 

Let  us  take  pachymeningitis  first.  This  is  characterized  by 
persistent  headache,  or  by  occasional  seizures  thereof,  by  giddiness, 
and  even  by  hemiparesis  in  the  intervals. 

But  on  the  other  hand,  there  is  no  congestion  of  the  disc,  except 
at  the  periods  of  ha3morrhage.  The  acute  exacerbations  resemble 
apoplectic  attacks,  which  is  not  the  rule  in  the  case  of  tumours.  It 
is,  however,  distinguished  from  ordinary  apoplexy  or  from  embolism 


ABSCESS,    PACHYMENINGITIS,    CYST,    AND    TUMOUR    OF    BRAIN  2  1 

by  the  predominance  of  spastic  symptoms  and  of  irritability.  If  we 
bear  in  mind  the  great  tendency  of  haemorrhagic  pachymeningitis  to 
relapse,  and  if  we  remember  that  most  of  its  victims  are  chronic 
alcohohcs  of  an  advanced  type,  the  diagnosis  will  not  usually  produce 
any  great  difficulty. 

This  subject  has  acquired  surgical  significance  since  good  results 
have  followed  operative  evacuation  of  hcematomata.  Obviously,  such 
treatment  can  neither  restore  the  condition  of  the  arteries  nor  convert 
the  patient  into  a  belated  total  abstainer. 

As  the  acute  exacerbations  often  come  on  after  a  fall,  the  following 
medico-legal  questions  are  important  : — 

(i)  Did  the  patient  fall  because  he  had  a  haemorrhage,  or  was  the 
haemorrhage  the  result  of  the  fall  ? 

(2)  Assuming  that  there  was  an  accident,  and  a  haemorrhage 
occurred,  was  the  latter  due  to  the  accident  or  to  the  antecedent 
alcoholism  ? 

After  considering  all  the  data  of  the  previous  history  and  the 
special  circumstances  of  the  "accident,"  an  expert  can  often  arrive  at 
a  definite  opinion  ;  but  nevertheless  these  cases  are  a  fruitful  source 
of  litigation. 

(3)  TRAUMATIC    CYSTS    OF   THE    BRAIN. 

The  diagnosis  between  tumour  and  traninatic  softening  or  cerebral 
cyst  is  difficult.  The  symptoms  may  be  so  much  alike  that  only  the 
history  supplies  the  decisive  factor.  If  the  patient  is  able  to  report  a 
severe  injury  to  the  skull,  evidence  of  which  we  can  find  on  the  scalp, 
the  lines  to  proceed  along  are  generally  clear.  It  will  be  necessary,  of 
course,  to  exclude  a  chronic  cerebral  abscess  as  far  as  the  progress 
of  the  case  and  the  temperature  chart  permit.  But  in  the  absence  of 
any  injury  to  the  skull,  the  matter  becomes  more  difficult.  A  most 
careful  examination  of  the  skin  covering,. and  of  the  surface  of  the 
skull  is  indispensable.  But  as  tumours  may  follow  injury,  one  should 
realize  a  further  fact  before  diagnosing  a  cyst,  i.e.,  the  duration  of 
symptoms — especially  epilepsy — for  years,  without  the  supervention 
of  new  indications,  and  without  any  essential  change  in  the  patient 
for  the  worse. 

A  man,  aged  54,  was  admitted  to  hospital  for  epileptic  attacks. 
The  symptoms,  principally  a  right-sided  hemianopia,  pointed  either 
to  a  cerebral  tumour  or  a  traumatic  cyst  of  the  brain.  A  careful 
examination  of  the  skull,  however,  revealed  a  small  scar  over  the 
left  occipital  region.  It  was  not  until  then  that  the  patient  remem- 
bered a  fall  on  the  head  off  a  hay  cart  in  his  youth.  The  diagnosis 
was,  therefore,  a  traumatic  cyst  of  the  brain,  which  was  confirmed  by 
the  operation. 

Sometimes  we  may  have  to  rely  on  an  obstetric  injury  by  forceps. 
If  no  history  of  any  kind,  pointing  to  an  injury,  is  available,  it  is 


22  SURGICAL   DISEASES    OF   THE    HEAD 

impossible  to  diagnose  a  cyst.  But  this  is  of  no  importance,  so  far 
as  treatment  goes,  because  a  tumour  which  can  be  localized  ought 
to  be  operated  upon,  if  surgically  feasible. 

Traumatic  cephalo-hydrocele,  a  special  variety  of  cerebral  cyst,  is 
referred  to  later  on. 

Another  special  variety  of  cerebral  cyst  consists  of  non-traumatic, 
separate  cystic  accumulations  in  the  soft  meninges,  especially  in  the 
vicinity  of  the  cerebellum.  Like  the  corresponding  changes  in  the 
spinal  cord,  they  possess  all  the  symptoms  of  tumour,  and  their 
diagnosis  can  only  be  established  at  the  operation. 

(4)    NEW  GROWTHS   AND    TUMOURS    OF    GRANULATION 

TISSUE. 

If  there  is  absolutely  nothing  pointing  to  abscess,  pachymeningitis 
or  cyst,  we  have  to  think  of  a  growth  within  the  skull,  viz.,  neoplasm, 
tubercle  or  giunina.  As  already  stated,  the  possibility  of  a  new  growth 
is  not  excluded  by  a  preceding  injury. 

This  is  well  illustrated  by  a  case  described  by  Friedrich,  wherein 
an  injury  suggested  the  presence  of  a  fibroma  in  the  frontal  lobe,  but 
the  essential  symptoms  were  of  psychical  origin. 

We  now  have  to  discuss  the  nature  of  the  tumour  which  may  be 
present.  It  would  be  ideal  if  we  could  infer  it  from  the  clinical 
symptoms.  But  as  gummata  and  solitary  tubercles  are  not  in- 
frequently extirpated  in  mistake  for  new^  growths,  it  is  evident  that 
we  have  not  yet  attained  this  ideal.  The  most  important  considera- 
tion for  the  diagnosis  is  offered  by  the  general  course  of  the  illness. 
As  a  rule  a  tumour  grows  steadily  on,  whereas  a  gumma  presents 
intermissions  in  its  course,  which,  therefore,  will  probably  be  irregular 
and  capricious. 

The  previous  history  and  the  systematic  examination  of  the  patient 
will  afford  us  more  information.  Careful  attention  must  be  paid  to 
everything  which  may  give  a  definite  lead  to  the  diagnosis,  without 
seizing  exclusively  on  any  one  point.  Severe,  rapidly  and  steadily 
increasing  symptoms  will  therefore  suggest  a  malignant  growth,  even 
if  the  patient  has  a  tubercular  family  history.  The  fact  that  the 
patient  has  had  syphilis  will  not  preclude  a  diagnosis  of  tumour  or 
tubercle,  if  there  is  definite  evidence  pointing  thereto.  Again,  a 
patient  who  has  for  some  time  been  exhibiting  symptoms  of  tumour, 
but  has  just  recovered  from  syphilis,  is  obviously  not  the  subject  of 
a  gumma. 

Too  much  importance  is  not  to  be  attached  to  a  negative  history 
of  syphilis,  in  view  of  the  fact  that  patients  may  be  genuinely  ignorant 
of  having  suffered,  especially  if  they  have  been  victims  of  "  lues 
insontium."  A  positive  Wassermann  reaction  is  very  significant, 
though  it  only  means  that  the  patient  has  had  syphilis   and  is  not 


ABSCESS,    PACHV.MEXIXGITIS,    CYST,    AXD    TUMOUR   OF   BKAIX         23 

completely  cured,  and  the  tumour  may,  after  all,  be  a  tubercle  or 
a  sarcoma. 

The  final,  and  often  the  decisive  diagnostic  point,  is  the  effect  of 
specific  treatment.  If  energetic  treatment,  not  unduly  prolonged,  is 
unsuccessful,  or  if  its  effect  is  doubtful,  the  patient  must  be  regarded 
as  a  "surgical  case,"  provided  any  focal  symptoms  are  evident,  no 
matter  whether  our  diagnosis  be  tumour,  tubercle^  or  traumatic  cyst. 
This  leads  us  to  the  problem  of  localization. 

Signs  of  paralysis  are  of  most  value,  because  these  give  a  more 
correct  indication  of  the  seat  of  pressure  than  do  symptoms  of 
irritation,  which  may  have  their  origin  in  the  regions  adjacent  to  the 
lesion.  Localization  is  easv  when  the  tumour  is  situated  in  the  motor 
area.  When  hciiiianopia  is  the  chief  symptom,  the  local  diagnosis 
demands  great  care,  because  this  may  be  due  either  to  a  lesion  in 
the  occipital  cortex  or  in  the  optic  tract.  If  it  is  possible  to  excite 
the  pupillary  reflex  from  the  blind  half  of  the  visual  field — the  so- 
called  hemianopic  pupillary  reaction  — the  tumour  is  probably  in 
the  visual  area.  If  this  reaction  is  not  present,  it  is  an  argument 
against  that  localization.  To  test  this  requires  the  full  consciousness 
of  the  patient  and  also  a  certain  amount  of  intelligence,  which  are  not 
always  present  in  cases  of  cerebral  tumour.  We  must  therefore  look 
for  assistance  from  other  symptoms,  and  basal  symptoms  will  almost 
certainly  be  in  evidence  when  a  tumour  is  pressing  upon  the  optic 
tract,  as  the  following  case  illustrates  : — 

A  young  man,  free  from  svphilitic  or  tubercular  antecedents,  fell 
ill  with  attacks  of  giddiness  and  headache.  Later  on,  he  also  suffered 
from  transitorv  mental  disturbance  and  aphasic  manifestations,  for 
which  he  was  brought  to  the  hospital.  A  careful  examination  showed 
right-sided  hemianopia,  paralysis  of  the  left  oculomotor  nerve,  very 
variable  speech  disturbance,  and  intermittent  mental  derangement. 
It  was  not  possible  to  obtain  the  hemianopic  pupillary  reflex  with 
any  certainty-,  but  the  discs  were  severelv  congested  on  both  sides. 
The  diagnosis  appeared  to  be  a  tumour  of  the  left  frontal  lobe, 
towards  the  base,  pressing  on  the  optic  tract.  This  was  the  only 
explanation  which  would  embrace  all  the  chief  symptoms — hemi- 
anopia, speech  disturbance,  and  paralysis  of  the  ocular  muscles.  The 
autopsy  revealed  a  sarcoma  as  big  as  a  fist  occupying  the  left  frontal 
lobe  and  growing  towards  the  base.  The  left  optic  tract  was  com- 
pressed into  a  strip  as  thin  as  a  piece  of  paper. 

It  is  always  necessary  to  seek  for  a  diagnosis  which  will  elucidate 
all  the  symptoms  simultaneously.  A  localization  which  assumes 
several  foci  of  disease  is  either  wrong  or,  if  well  attested,  must  also 
assume  a  disease  wherein  the  lesions  may  be  multiple,  like  gumma, 
tubercle,  or  secondary  growths,  and  not  merely  a  single  new  growth. 

The  details  of  cerebral  localization  are  given  in  Chapter  VI,  but  we 
append   here  a  brief  outline  of  the  diagnostic  symptoms  of  tumours. 


24  SURGICAL   DISEASES   OF   IHE   HEAD 

according  to  their  localization.  The  same  symptoms  naturally  hold 
good  for  abscesses  and  cysts.     {Compare  figs.  6  to  lo.) 

Frontal  Lobe. — Psychical  disturbances,  mental  disease,  sexual  per- 
version, loss  of  memory,  fine  tremor  of  same  side,  hemiparesis  of 
opposite  side,  ocular  paralysis  (extrinsic  muscles),  compression  of 
optic  tract,  unilateral  congestion  of  disc,  aphasia  frequent  when 
tumour  is  on  left  side. 

Region  of  Pre-ceniral  Snlcns. — Signs  of  motor  irritability  or  of 
paralysis  on  opposite  side.  Extent  of  symptoms  depends  upon  extent 
of  tumour. 

Parietal  Lobe. — Loss  of  all  perceptions  comprehended  under  the 
term  of  "muscle  sense."  When  of  considerable  extent,  symptoms 
arise  from  adjacent  area,  such  as  motor  disturbance,  signs  of  acute 
irritation,  hemianopia,  and,  if  the  tumour  be  on  the  left  side,  sensory 
aphasia,  word-blindness  and  agraphia. 

Temporal  Lobe. — Sensory  aphasia  (left  side). 

Occipital  Lobe  and  Cnnens. — Symptoms  of  optic  irritation,  homony- 
mous hemianopia,  mind-blindness. 

Cerebello-pontine  Angle. — Trigeminal  neuralgia,  tinnitus,  deafness, 
labyrinthine  giddiness,  paralysis  of  adjacent  nerves,  especially  the 
sixth  and  seventh. 

Region  o/Po7«.— Spastic  paralysis  of  the  opposite  limbs.  Paralys  s 
of  sixth  and  seventh  nerves  of  same  side. 

Cerebellum. — Pain  back  of  neck,  giddiness,  early  onset  of  double 
optic  neuritis,  rigidity  of  posterior  cervical  muscles,  cerebellar  ataxia 
(tendency  to  fall  towards  side  of  tumour),  vertigo,  nystagmus,  forced 
movements,  distant  effect  on  contiguous  nerves. 

Pituitary  Gland. — Pressure  signs  on  optic  chiasma,  i.e.,  bitemporal 
hemianopia,  ending  in  complete  blindness.  This  symptom  is  almost 
pathognomonic  of  a  pituitary  tumour,  in  the  absence  of  such  a  cause 
as  a  fractured  skull  or  a  gunshot  wound.  There  are  often  associated 
symptoms  dependent  upon  the  functions  of  growth,  attributed  to  the 
pituitary  body,  i.e.,  acromegaly  on  the  one  hand  (the  result  of  hyper- 
secretion), and  on  the  other  a  form  of  general  obesity  accompanied 
by  defective  genital  development  (typus  adiposo  genitalis)  (the  result 
of  deficient  function).  An  example  of  the  latter  variety  will  show  how 
we  arrive  at  the  diagnosis  of  a  pituitary  tumour  :— 

A  boy,  aged  lo,  had  been  observed  to  squint  since  he  was  2  years 
old,  and  from  the  age  of  4  there  had  been  defective  vision,  which 
culminated  in  complete  blindness  of  the  left  eye.  On  examination, 
his  appearance  was  very  reminiscent  of  myxoedema,  especially  his  dry 
scaly  skin  and  defective  genital  development.  But,  in  contrast  to  what 
generally  obtains  in  hypothyroidism,  his  intelligence  was  normal. 
His  puffy  appearance  was  more  definitely  due  to  deposits  of  fat  than 
is  the  case  in  myxoedema.  The  thyroid  gland  was  present,  but  was 
rather  small.  The  possibility  of  the  presence  of  pituitary  disease  was 
entertained,  especially  as  his  mother  said  that  he  w^as  particularly 
sensitive  to  blows  or  touches  all  over  his  body.  Dercum,  years  ago, 
looked  upon  adiposis  dolorosa  as  a  pituitary  symptom,  and  this  view 
has  again  been  put  forward  of  late  by  Froelich  and  others.     If  this 


CEREBRAL   COMPLICATIONS    OF   SUPPURATIVE    OTITIS    MEDIA  25 

assumption  were  correct  in  the  present  case,  it  would  follow  that 
tempoi-al  hemianopia  would  be  present  in  the  right  eye,  which  was 
not  yet  completely  blind.  As  a  matter  of  fact,  it  was  found  that  this 
symptom  could  be  clearly  demonstrated,  and  in  addition  both  optic 
nerves  showed  signs  of  atroph3^  Thus  the  diagnosis  of  pituitary 
tumour  was  established.  The  slow  growth  of  the  tumour  indicated 
that  it  was  not  a  sarcoma,  but  probably  a  very  slowly  progressive 
adenoma,  comparable  to  a  goitre  of  the  thyroid  gland.  A  skiagram 
showed,  in  confirmation  of  the  clinical  signs,  a  great  widening  of  the 
sella  turcica. 

I  have  purposely  refrained  from  mentioning  puncture  of  the  brain 
to  determine  the  nature  and  situation  of  a  tumour,  as  recommended 
by  Neisser.  The  procedure  is  too  dangerous  and  its  results  are  too 
doubtful  for  it  to  be  regarded  as  of  diagnostic  assistance  to  the 
practitioner.  It  may,  however,  be  a  useful  expedient  for  the  surgeon, 
when  everything  is  ready  for  an  operation. 

Rontgen-ray  examination  is  harmless.  It  will  reveal  calcified  or 
osseous  tumours,  and  confirm  the  diagnosis  of  pituitary  tumours  by 
showang  a  widened  sella  turcica. 


CHAPTER    IV. 

THE   CEREBRAL   COMPLICATIONS   OF 
SUPPURATIVE   OTITIS   MEDIA. 

Although  all  the  cerebral  complications  of  otitis  media  do  not 
originate  from  mastoid  abscess,  nevertheless  it  is  their  principal  cause. 
It  reminds  us  that  the  otitis  is  no  longer  a  minor  malady,  but  that  it 
has  reached  a  stage  wherein  danger  to  the  brain  is  to  be  apprehended 
— a  danger  which  can  be  prevented  by  timely  treatment.  It  is  the 
habit  of  auial  surgeons  to  distinguish  between  acute  and  chronic 
mastoiditis,  but  as  the  clinical  symptoms  of  both  varieties  are  identical^ 
we  shall  consider  them  together. 

We  must  clearly  understand  that  we  are  not  clinically  diagnosing 
a  suppurative  catarrh  of  the  mucous  lining  of  the  mastoid  antrum,  but 
its  resulting  consequence.  As  long  as  the  pus  can  freely  escape  from 
the  antrum  we  have  no  means  of  diagnosing  a  mastoiditis.  Com- 
parative transillumination  and  percussion  may  guide  us  occasionally, 
but  it  cannot  establish  the  diagnosis.  It  is  only  when  the  pus  is 
retained,  and  damage  occurs  to  the  bone  or  periosteum,  when  caries 
develops   or  a  sequestrum   forms,   that  definite  clinical   signs  appear 


26  SURGICAL   DISEASES   OF   THE    HEAD 

which  proclaim  the  course  of  the  disease.  This  holds  good  whether 
the  caries  be  acute  or  chronic.  Very  many  apparently  trifling  cases  of 
otitis  are  accompanied  by  suppuration  within  the  adjacent  antrum, 
without  our  being  aware  of  it.  This  suppuration  is  comparatively 
harmless  as  long  as  it  does  not  lead  to  the  results  just  mentioned. 
That  the  recognition  of  these  sequelae  is  important  is  obvious  enough 
from  Pitt's  voluminous  statistics,  v/hich  show  that  the  cerebral 
complications  of  otitis  are  responsible  for  |  per  cent,  of  all  deaths. 
As  most  of  these  cases  result  from  chronic  otitis,  it  is  clear  that  our 
first  diagnostic  task  is  to  recognize  those  cases  of  chronic  otitis  media 
which  may  be  rescued  by  timely  surgical  treatment  from  subsequent 
complications  of  a  severe  character.  If  we  only  diagnose  that  our 
patient  has  a  "  chronic  otorrhoea,"  our  services  will  not  have  been  of 
much  value.  Neither  does  a  diagnosis  of  "  polypus  of  the  ear  "  get  to 
the  root  of  the  matter.  If  we  say  that  there  is  chronic  suppurative 
catarrh  behind  the  polypus,  and  that  something  is  keeping  up  this 
catarrh,  we  shall  be  more  nearly  approaching  the  truth.  If  we  know 
that  the  discharge  is  frequently  foetid,  that  the  child  often  complains  of 
headache,  and  if  the  region  behind  the  concha  is  occasionally  painful 
on  pressure,  we  should  not  be  content  with  diagnosing  otorrhoea  or 
polypus,  but  must  inform  the  relatives  that  a  serious  disease  is  present 
• — 3.  disease  with  dangerous  features,  which,  however,  can  be  obviated 
or  rendered  harmless  by  operation.  If  the  aural  discharge  has  lasted 
many  years,  the  term  cholesteatoma  is  often  applied  to  the  malady. 
This  is  not  really  a  tumour,  but  merely  the  result  of  a  chronic 
desquamative  inflammation. 

It  should  be  said  that  there  are  tumours  which  correspond  to  the 
"cholesteatoma"  of  the  older  pathologists,  but  these  have  little  concern 
with  the  diseases  of  the  ear. 

The  following  is  a  typical  case  of  the  ordinary  aural  chole- 
steatoma : — 

A  little  boy  with  an  old-standing  ear  discharge  was  admitted  to 
the  hospital  on  account  of  an  aural  polypus.  The  discharge  was 
offensive,  the  region  behind  the  ear  sensitive,  but  neither  swollen  nor 
inflamed.  There  were  no  acute  symptoms,  temperature  was  normal, 
and  the  general  condition  was  good.  Diagnosis  :  CJiolesteatoma.  The 
operation  revealed  a  cholesteatoma  larger  than  a  pigeon's  egg,  bathed 
in  foetid  liquid,  which  had  exposed  the  dura  mater  to  the  extent  of 
i^  sq.  cm. 

Sometimes  such  a  condition  lasts  a  whole  lifetime.  I  have  seen 
a  cholesteatoma  excite  brain  symptoms  forty  years  after  the  start  of 
the  aural  suppuration. 

There  are  two  further  points  which  support  the  diagnosis  of 
cholesteatoma.  The  first  is,  that  most  cases  follow  the  very  destructive 
scarlatinal  form  of  otitis  media,  and  the  second  is,  that  the  perforation 
of  the   drum  is  not  central,  but  in  the  upper  segment.     Experience 


CEREBRAL    COMPLICATIONS    OF   SUPPURATIVE    OTITIS    MEDIA 


27 


shows  that  cases  of  chronic  otitis  media  with  a  central  perforation  are 
less  likely  to  lead  to  cerebral  complications  and  recover  more  easily, 
after  appropriate  treatment,  than  cholesteatomata,  which  always  require 
surgical  measures. 

Ouv  stxond  diagnostic  task,  both  in  acute  and  chronic  otitis  media, 
is  to  recognize  forthwith  the  onset  of  severe  mastoid  complications,  in 
order  to  prevent,  by  means  of  a  timely  operation,  the  extension  of  the 
infection  to  the  brain.  When  the  infection  is  severe,  especially  after 
scarlet  fever,  a  decision  must  be  made  within  a  few  hours;  days  cannot 
be  afforded  for  the  purpose.  It  is  easy  to  overlook  the  beginning  of  a 
mastoid  inflammation  in  a  child 
who  is  already  very  ill,  but  this 
oversight  may  cost  its  life, 

A  sudden  cessation  of  tJie 
disdiarge,  with  a  simultaneous 
aggravation  of  the  snbjcctivc 
symptoms,  despite  the  existence 
of  a  perforation  of  a  drum, 
should  arouse  suspicion.  In- 
crease of  the  pain  indicates 
retention,  and  the  open  perfor- 
ation shows  that  the  retention 
is  deep  within  the  adjacent 
antrum. 

Our  view  is  confirmed  if 
we  obtain,  on  comparing  the 
two  sides,  definite  tenderness  of 
the  mastoid  process  on  pressure, 
provided  that  our  examination 
is  properly  conducted.  We 
may  be  deceived  by  a  painful 
swelling  of  the  glands  situated 

over  the  mastoid,  which  may  enlarge  after  a  superficial  inflammation 
of  the  external  auditory  canal.  But  careful  palpation  will  avoid  any 
difSculty  on  the  score  of  these  painful  glands,  because  of  their  limited 
outline  and  because  the  bone  beneath  is  not  tender  on  pressure.  If  the 
inflammation  of  the  external  auditory  passage  is  intense,  the  periosteum 
in  relation  with  it  may  become  tender  on  pressure,  without  any  sup- 
puration in  the  air  cells  being  necessarily  present.  Tenderness  limited 
to  the  posterior  portion  of  the  mastoid  process  is  not,  as  such,  a  con- 
clusive proof  of  a  mastoiditis.  It  is  one  of  the  chief  symptoms  of 
phlebitis  of  the  emissary  vein  of  the  mastoid,  and  is  only  an  indirect 
indication  of  suppuration  within  the  mastoid  cells  ;  but,  of  course, 
it  equally  demands  operation. 


Fig.  4. 


-Bulging  of  the  ear  in  mastoid 
inflammation. 


28 


SURGICAL   DISEASES   OF   THE    HEAD 


The  remarks  concerning  tenderness  on  pressure  apply  also  to  the 
swelling  of  the  soft  tissues  which  cover  the  bone.  Inflammation  of 
the  lymphatic  glands  and  phlebitis  may  each  be  a  source  of  error,  but  if 
the  possibility  of  these  be  borne  in  mind,  no  mistake  is  likely  to  arise. 

A  definite  bulging  of  the  ear  away  from  the  head  (fig.  4)  is  an 
important  sign  of  mastoiditis. 

A  reddening  of  the  skin  gives  unmistakable  support  to  the  diagnosis, 
as  long  as  it  has  not  been  caused  by  painting  iodine  or  applying 
a  blistering  plaster. 

Must  all  these  signs  be  present  to  justify  the  diagnosis  of  mastoid- 
itis ?     Those  who  have 

/  lll)„l  ,  1  v\>^:i^:^:^V>\\^^^ 


often  operated  for  mas- 
toid disease  know  that 
there  maybe  severe  sup- 
puration, and  even  se- 
questrum formation,  in 
cases  which  have  pre- 
sented but  little  tender- 
ness, and  which  have 
had  neither  swelling  nor 


reddening  of  the  mas- 
toid process.  We  must 
therefore  take  the  other 
symptoms  into  con- 
sideration, principally 
the  temperature  and 
the  subjective  feelings 
of  the  patient.  If  the 
original  symptoms  of 
an  acute  otitis  have  sub- 
sided, and  then  there 
is  another  rise  of  tem- 
perature accompanied 
by  pain  behind  the  ear, 
or  if  these  symptoms  ap- 
pear during  the  course 
of  a  chronic  otitis,  we 
may  infer  the  presence  of  mastoid  disease,  although  the  external  visible 
sign  may  be  indefinite.  We  may  explain  facial  paralysis  following 
aural  suppuration  in  the  same  way.  It  should  not  be  forgotten  that, 
exceptionally,  mastoid  disease  can  occur  without  suppuration  in  the 
tympanic  cavity. 

If   cerebral  complications  have   supervened,   our  third  diagnostic 
task    is    to    determine    their    character    accurately.      Two    practical 


Fig.  5- —  Diagram  of  inflammatory  complications  in  sup- 
puration of  the  temporal  bone  area.  Green  =  pus;  red  = 
inflamed  menmges  ;  blue  =:  venous  sinus;  violet  =  throm- 
bosed sinus,  a  =  mastoid  antrum  ;  b  =  mastoid  process 
cells  ;  c  =  thrombosed  transverse  sinus ;  d  subdural 
abscess;  e  ^=  abscess  in  temporal  lobe;  /=  cerebellar 
abscess  ;  g  =  abscess  under  the  sterno-mastoid  (Bezold's 
abscess). 


CEREBRAL   COMPLICATIONS   OF   SUPPURATIVE   OTITIS    MEDIA  29 

questions  are  of  urgent  importance,  viz.,  are  the  observed  symptoms 
only  sympathetic  and  reflex,  or  are  they  due  to  anatomical  changes 
within  the  skull  ?  If  the  latter,  do  these  represent  an  epidural 
abscess,  a  cerebral  abscess,  meningitis,  or  thrombophlebitis  of  the 
transverse  sinus  ? 

The  correct  interpretation  of  these  questions  is  of  decisive  signifi- 
cance to  the  life  of  the  patient. 

It  is  obvious  that  an  acute  suppurative  process  in  close  proximity 
to  the  brain  has  some  effect  thereon.  Every  enclosed  focus  of 
infection  is  surrounded  by  a  zone  of  circulaiory  disturbance,  and  in 
the  case  of  a  focus  in  the  ear,  the  neighbouring  area  of  brain  and  its 
sheaths  may  be  involved.  This  explains  the  existence  of  a  congested 
disc  without  any  further  changes  within  the  skull. 

In  addition  to  local  circulatory  disturbances,  there  are  the  pure 
rejiex  processes,  which  are  especially  well  marked  in  children,  and  the 
symptoms  of  a  general  intoxication.  Delirium,  convulsions,  and  even 
rigidity  of  the  neck,  when  they  occur  in  the  first  acute  onset  of  an 
otitis,  or  in  mastoiditis,  must  not  forthwith  be  put  dou^n  to  menin- 
gitis. We  should  be  content  with  opening  the  local  focus  of  suppura- 
tion in  the  tympanum  or  in  the  mastoid  process,  and  carefully 
watching  the  course  of  events.  Actual  cerebral  complications  take 
a  definite  time  to  develop,  usually  a  few  days.  They  do  not  accompany 
the  first  aural  symptoms,  not  even  in  rapidly  acute  cases  ;  but  they 
follow  them.  But  if  such  symptoms  persist  after  the  mastoid  process 
has  been  properly  drained,  or  if  they  occur  afresh,  then  not  only  are 
we  justified  in  diagnosing  an  intracranial  complication,  but  we  are 
compelled  to  do  so  and  to  act  upon  it. 

We  have  hitherto  been  deaUng  with  the  matter  from  the  point  of 
view  of  an  acute  onset  of  otitis  or  mastoiditis.  But  this  is  not  an 
invariable  aspect.  Discharge  from  the  ear — chronic  otitis — may  have 
been  present  for  years.  Occasionally  there  is  a  temporary  cessation 
of  the  discharge  and  the  patient  feels  a  dull  pain  deeply  within  the 
ear.  The  thermometer  indicates  a  slight  rise  in  temperature,  but  the 
patient,  accustomed  as  he  is  to  his  malady,  consults  neither  a  ther- 
mometer nor  a  doctor.  He  knows  that  the  discharge  will  soon  start 
again,  and  he  is  content.  But  a  fortnight  or  three  weeks  after  this 
scarcely  noticed  incident,  there  supervene  headache  and  giddiness, 
without  anything  remarkable  occurring  in  the  ear.  Perhaps  the 
patient  may  forget  to  tell  the  doctor  that  he  has  been  suffering  from 
an  aural  discharge.  Such  cases  as  these  are  really  more  serious 
than  those  which  exhibit  convulsions  and  delirium  during  an  acute 
otitis. 

What  is  happening  within  the  skull  ?  Are  we  dealing  with  an 
epidural  abscess,  a  meningitis,  a  cerebral  abscess,  or  a  sinus  thrombosis  f 


30  SURGICAL    DISEASES    OF    THE    HEAD 

The  condition  of  least  gravity  is  that  of  epidural  abscess,  i.e.,  a 
collection  of  pus  between  the  roof  of  the  petrous  portion  of  the 
temporal  bone  and  the  dura  mater,  or  more  rarely  posteriorly, 
between  the  petrous  and  the  transverse  sinus.  These  abscesses  may 
be  so  free  from  symptoms  that  they  are  discovered  quite  accidentally 
when  opening  the  antrum  for  mastoiditis.  It  is  perhaps  not  correct 
to  term  their  discovery  ''  accidental,"  because  the  experienced  surgeon 
will  inspect  the  roof  of  the  antrimi  in  every  case  wherein  he  opens 
the  mastoid  process.  If  he  has  any  suspicion  of  epidural  abscess  he 
will  not  hesitate  to  expose  a  limited  area  of  dura,  so  as  not  to  miss  it. 
If  the  abscess  is  large,  it  will  cause  slight  pressure  symptoms  :  head- 
ache, somnolence,  a  somewhat  slow  pulse  and  a  typical  pus  tempera- 
ture.    Really  severe  brain  symptoms  do  not  usuallv  occur. 

It  IS  very  exceptional  to  find  any  svmptoms  of  local  pressure,  and 
then  only  in  children.  These  concern  the  adjacent  cortical  areas  and 
cause  aphasia  when  the  lesion  is  on  the  left  side,  and  motor  dis- 
turbances when  the  accumulation  of  pus  is  very  extensive. 

If  the  symptoms  do  not  unanimouslv  point  to  a  simple  mastoiditis, 
our  first  thought  should  be  of  an  "  epidural  abscess,"  although  the 
condition  of  the  patient  mav  not  appear  to  us  to  be  particularly 
disquieting.  We  may  console  ourselves  and  the  relatives  with  this 
diagnosis,  and  yet  we  must  confess  that  the  pus  may,  after  all,  be  on 
the  other  side  of  the  dura.  .  So  that  anyone  who  explores  for  an 
epidural  abscess  must  be  prepared  to  extend  his  search,  if  necessary, 
beyond  the  dura  into  the  brain  substance. 

But  are  there  no  svmptoms  which  enable  us  to  diagnose  a  cerebral 
abscess  forthwith  ?  Let  us  first  consider  the  fairlv  common  abscess 
of  the  temporal  lobe,  which  damages  the  same  cortical  area  as  an 
epidural  abscess,  when  in  its  usual  position  on  the  roof  of  the  petrous 
bone.  We  shall  discuss  cerebral  abscess  later  on.  Theoretically, 
we  may  anticipate,  from  a  temporal  lobe  abscess  on  the  right  side, 
a  diminution  of  auditor}'  perception  in  the  left  ear.  But  as  the  right 
ear  is  not  available  for  comparison,  apart  from  the  fact  that  both  ears 
are  often  affected  in  otitis,  we  must  discard  this  test.  An  abscess  in 
the  left  temporal  lobe  may  cause  sensoiy  aphasia,  but  does  not  always 
do  so.  Although  it  is  conceivable,  as  already  stated,  that  an  extensive 
epidural  abscess  may  cause  a  certain  measure  of  aphasia,  owing  to 
pressure  upon  the  temporal  lobe,  nevertheless  a  definite  sensory 
aphasia  must  be  put  down  to  the  credit  of  a  cerebral  abscess.  But  in 
the  absence  of  aphasia,  or  when  the  disease  is  on  the  right  side,  we 
must  draw  our  conclusion  from  the  intensity  of  the  symptoms.  If  the 
headache,  slow  pulse  and  vomiting  are  very  marked,  or  if  uncon- 
sciousness be  present,  there  is  much  greater  probability  of  cerebral 
abscess  than  of  a  simple  epidural  abscess.     The  temperature  can  be 


CEREBRAL    COMPLICATIONS    OF   SUPPURATIVE    OTITIS    MEDIA  31 

relied  upon  as  a  guide.  On  the  whole,  an  epidural  abscess  is  more 
likely  to  exhibit  the  regular  curve  of  a  pus  temperature  than  a  cerebral 
abscess,  wherein  the  temperature  is  quite  irregular.  Days  with  normal 
temperature  alternate  with  sudden  and  steep  ascents  in  the  chart. 
One  must  not  neglect  the  "  impression "  conveyed  by  the  patient. 
A  patient  with  an  epidural  abscess  does  not  convey  the  impression 
of  a  severe  case.  The  general  condition  of  a  case  of  cerebral  abscess 
does  not  give  rise  to  great  anxiety,  except  in  the  last  stage.  Never- 
theless a  careful  observer  will  detect  "something"  in  the  psychical 
state  which,  however,  baffles  definition.  If  the  patient  is  a  child  the 
parents  are  quite  sure  that  there  is  some  "change,"  and  a  mother's 
observation  is  often  more  acute  than  that  of  the  medical  attendant. 
In  diffuse  purulent  uieningitis  the  clinical  picture  is  quite  different. 
The  existence  of  a  severe  illness  is  in  striking  evidence.  As  this 
impression  gains  in  intensity  from  hour  to  hour,  the  diagnosis  no 
longer  remains  in  doubt,  for  there  is  a  steady  progress  in  meningitis, 
whereas  in  cerebral  abscess  the  course  is  fluctuating. 

The  following  is  a  typical  case  of  an  abscess  in  the  temporal  lobe, 
following  otitis  : — 

A  little  girl  had  been  suffering  from  a  discharge  from  the  left  ear 
for  several  years.  She  began  to  complain  of  severe  pain  behind  the 
left  ear  three  weeks  before  admission  to  the  hospital.  The  mother 
thought  that  there  was  a  slight  swelling,  but  the  pain  ceased  on  the 
application  of  domestic  remedies,  and  the  child  returned  to  school, 
apparently  in  normal  health.  Then,  severe  headache  and  vomiting 
set  in,  and  the  doctor  noted,  at  that  time,  a  slight  facial  paralysis  of 
the  left  side.  There  was  a  little  tenderness  behind  the  ear,  but  no 
swelling,  though  an  offensive  discharge  issued  from  the  meatus.  There 
was  neither  aphasia  nor  congestion  of  the  discs ;  the  pulse  was  not 
retarded,  and  there  was  only  a  little  fever.  The  facial  paralysis  in- 
dicated a  severe  inflammatory  process  within  the  temporal  bone,  and 
the  long  duration  of  the  disease,  together  with  the  offensive  discharge, 
made  the  diagnosis  of  cholesteatoma  very  probable.  The  headache 
and  vomiting  made  one  think  of  abscess,  but  these  symptoms  may 
have  been  remote  ones.  The  operation,  which  was  undertaken 
immediately,  revealed  a  cholesteatoma  bathed  in  foetid  pus.  The 
facial  nerve  canal,  seen  on  the  floor  of  the  large  bony  space,  was 
eaten  away  into  an  open  channel.  There  was  improvement  for  two 
days  after  the  operation  ;  then  the  headache  recurred,  with  striking 
changes  in  the  psychical  condition  and  signs  of  aphasia.  Congestion 
of  the  left  disc  was  beginning,  and  therefore  a  diagnosis  of  abscess  in 
the  left  temporal  lobe  was  made.  A  second  operation  revealed  an 
enormous  abscess  in  this  position,  filled  with  foetid  fermenting  pus. 
The  aphasia  disappeared,  the  mental  condition  became  normal,  and 
in  a  few  weeks  the  child  left  the  hospital,  completely  cured  except  for 
a  remaining  facial  pai"alysis. 

The  diagnosis  of  cerebral  abscess  presents  greater  difficulties.     Just 


32  SURGICAL   DISEASES   OF^  THE    HEAD 

as  a  temporal  lobe  abscess  is  the  consequence  of  the  spread  of  the 
inflammation  upwards,  so  is  cerebellar  abscess  the  consequence  of 
its  spread  backwards.  The  bone  is  not  necessarily  destroyed,  but  the 
transverse  sinus,  which  runs  in  the  direction  of  the  cerebellum,  is 
frequently  involved.  If,  therefore,  signs  of  a  cerebral  abscess  follow 
those  of  a  sinus  thrombosis,  our  first  thought  will  be  of  the  cerebellum. 
The  only  other  symptom  which  points  to  this  diagnosis  is  giddiness, 
of  the  character  of  cerebellar  ataxia.  But  it  must  not  be  forgotten 
that  any  intracranial  disease  can  cause  giddiness,  and  that  if  the 
giddiness  be  very  severe  it  may  depend  upon  the  labyrinth  being 
affected.  To  make  the  diagnosis  of  cerebellar  abscess  probable,  the 
cardinal  signs  of  a  cerebral  abscess  must  be  preseiit,  viz.,  headache, 
vomiting,  and  possibly  slow  pulse  and  congested  disc,  and  in  addition 
a  giddiness  which  causes  the  patient  to  stagger,  or  even  entirely 
prevents  him  from  walking.  If  a  sinus  thrombosis  is  also  present 
it  supports  the  diagnosis,  because  it  shows  that  the  inflammatory 
process  has  extended  backwards,  but  on  the  other  hand  this  throm- 
bosis may  itself  cause  symptoms  similar  to  those  of  a  cerebellar 
abscess.  It  is  therefore  prudent  to  give  the  first  signs  of  a  thrombosis 
the  opportunity  of  disappearing  before  proceeding  in  search  of  a 
cerebellar  abscess, 

The  following  is  a  classical  case  of  cerebellar  abscess  : — 
A  young  man,  the  subject  of  an  old  chronic  otitis,  suffered  from 
an  abscess  behind  the  left  ear.  His  medical  attendant  opened  it  by 
means  of  Wilde's  incision,  and  rapid  healing  followed  ;  but  tiie  patient 
began  to  complain  of  headache  and  giddiness  a  few  weeks  later.  The 
pulse  became  slow  and  irregular,  and  definite  signs  of  a  cerebral 
abscess  appeared.  Giddiness  was  the  only  symptom  af  localizing 
value,  and  it  was  so  intense  that  the  patient,  whose  nervous  system 
was  otherwise  healthy,  could  hardly  walk.  Operation,  and  unfor- 
tunately the  subsequent  autopsy,  confirmed  the  presence  of  the 
expected  abscess. 

How  can  we  recognize  sinus  thrombosis?  Its  brain  symptoms 
are  of  least  significance.  Of  course,  the  blocking  up  and  the  infective 
inflammation  of  a  large  venous  channel  will  produce  a  disturbance  in 
the  cerebral  circulation  which  will  manifest  itself  by  certain  signs,  but 
these  are  so  indefinite  that  no  diagnosis  can  be  based  on  them.  There 
will  be  headache,  vomiting  and  giddiness  in  cases  of  meningitis,  just 
as  there  are  in  cases  of  abscess.  But  there  are  some  special  features 
which  permit  us  to  recognize  disease  of  the  sinus.  These  consist  of 
changes  in  the  veins  connecting  with  the  sinus.  Frequently  there  is 
tenderness  over  the  region  of  the  emissary  vein  in  the  posterior  portion 
of  the  mastoid  process  ;  occasionally  there  may  be  oedematous  swelhng 
due  to  the  spread  of  the  thrombus  externally,  through  the  emissary 
vein. 


CEREBRAL   COMPLICATIONS   OF   SUPPURATIVE    OTITIS   MEDIA  33 

Special  attention  must  be  paid  to  the  condition  of  the  internal 
jugular  vein,  which  usually  shares  in  the  thrombophlebitis,  at  any 
rate  in  its  upper  section,  which  presents  in  its  course  some  oedema, 
in  the  form  of  a  cylindrical  painful  swelling.  If  these  signs  follow 
a  previous  aural  discharge  they  suffice  for  a  correct  diagnosis.  But 
this  swelling  behind  the  mastoid  process  must  not  be  confused  with 
the  deep  cervical  abscesses,  which  are  occasionally  noticed  after  acute 
and  chronic  middle-ear  suppuration,  and  which  may  spread  thence 
over  the  entire  side  of  the  neck.  I  have  seen  an  abscess  of  this  kind 
— a  fermenting  phlegmon — reach  clown  to  the  gluteal  region.  This 
variety  of  abscess,  first  described  by  Bezolt,  may  follow  a  purulent 
sinus  thrombosis,  but  this  is  not  its  only  cause. 

If  we  suspect  a  sinus  thrombosis  in  the  absence  of  definite  local 
signs,  the  diagnosis  can  be  established  in  severe  cases  by  the  general 
symptoms  of  an  infective  thrombophlebitis.  Repeated  rigors  followed 
by  characteristic  outburst  of  perspiration,  sudden  elevations  of  the 
temperature  up  to  104° — 6°  F.,  a  pulse-rate  of  140  or  more,  and  the  sub- 
sequent onset  of  pulmonaiy  embolism — all  these  form  a  clinicaf 
picture  which  once  seen  is  never  forgotten,  and  which  even  the 
inexperienced  cannot  fail  to  recognize. 

The  only  thing  which  now  remains  is  meningitis.  If  the  sym- 
ptoms do  not  fit  in  with  any  of  the  previously  described  conditions,  we 
may  diagnose  it  by  a  process  of  exclusion.  The  disease  is  ushered  in 
by  headache,  stiffness  of  the  neck,  vomiting  and  fever.  From  the 
very  beginning  the  aspect  is  grave,  and  the  gravity  increases  from 
hour  to  hour.  Sleeplessness  alternates  with  delirium,  and  as  the 
disease  advances  unconsciousness  becomes  more  marked.  Motor 
symptoms  of  irritation  and  paralysis  may  come  on  without  any 
definite  order,  and  in  the  most  variable  combinations,  but,  on  the 
other  hand,  they  may  remain  entirely  absent.  The  fever  persists, 
the  slow  pulse  becomes  rapid,  the  respiration  interrupted,  and  death 
ensues  in  profound  coma. 

If  the  diagnosis  is  doubtful,  it  may  be  cleared  up  by  lumbar 
puncture.  A  negative  result  would  justify  us  in  searching  for  a 
cerebral  abscess,  but  if  the  fluid  is  cloudy,  operative  interference  is 
useless.  The  few  cases  of  otitic  meningitis  which  have  recovered  after 
trephining  were  of  a  circumscribed  character.  We  must  endeavour 
to  operate  m  meningitis  before  the  fluid  has  become  cloudy  as 
low  down  as  the  lumbar  spine. 


34  SURGICAL   DISEASES   OF   THE    HEAD 

CHAPTER   V. 

THE   PROBLEM   OF   EPILEPSY. 

The  surgeon  occasionally  sees  all  three  varieties  of  epileptics.  He 
is  most  frequently  concerned  with  those  who  suffer  in  consequence  of 
previous  injury,  then  with  those  whose  epilepsy  depends  upon  a  non- 
traumatic anatomical  lesion  of  the  brain,  and  finally  genuine  epileptics 
find  their  way  to  him  when  medical  treatment  can  offer  no  relief. 
As  the  surgeon  has  to  pronounce  the  final  verdict  in  regard  to  opera- 
tion in  any  given  case,  he  must  be  able  to  decide  to  which  class  the 
patient  belongs. 

The  first  thing  to  decide  is,  whether  the  patient  is  really  epileptic, 
and  here  the  difficulty  begins.  We  will  assume  that  no  gross  diagnostic 
blunder  has  been  committed,  and  that  neither  uraemia  nor  eclampsia 
has  been  mistaken  for  epilepsy.  It  is  important,  however,  to  recog- 
nize accurately  the  so-called  "epileptiform"  attacks,  and  those '  of 
"petit-mal,"  and  to  distinguish  the  violent  epileptic  seizures  in  hysteri- 
cal conditions.  The  differential  diagnosis  of  this  last  group  of  cases, 
which  we  cannot  here  discuss,  is  not  always  very  easy,  especially  when 
the  tongue  is  not  bitten,  when  other  self-inflicted  injuries  are  absent, 
and  when  the  moral  perversity  may  be  attributed  to  either  one  or  the 
other. 

As  just  stated,  the  surgeon's  most  frequent  opportunities  for 
seeing  epileptiform  attacks  are  in  post-traumatic  cases.  The  following 
is  an  instance  : — 

The  patient  was  a  young  man  of  a  low  psychopathic  type,  afraid  of 
work  and  prone  to  lying.  He  sustained  a  stab  in  the  side  with  a  knife  ; 
the  wound  healed  rapidly,  but  he  developed  epileptiform  attacks, 
which  kept  many  observers  in  doubt  for  weeks  as  to  their  epileptic  or 
hysterical  character.  He  was  sent  from  one  hospital  to  another  ;  he 
ran  away  at  times  and  simulated,  consciously  or  unconsciously,  the 
most  varied  diseases.  He  wanted  to  be  trephined,  to  have  his  thorax 
explored,  to  have  a  laparotomy  performed,  and  he  also  indulged  in 
attacks  of  mild  self-injury,  &c. 

It  really  matters  little  whether  such  an  afflicted  individual  is 
diagnosed  as  an  epileptic  or  a  hysteric  or  as  a  combination  of  the 
two.  His  motor  functions,  like  the  rest  of  his  nervous  system,  are  in 
a  state  of  intense  irritability,  and  a  prudent  surgeon  will  leave  him 
severely  alone. 

But,  assuming  that  the  case  is  one  of  real  epilepsy,  we  have  to 
consider  the  clinical  history,  the  course  of  the  attack,  and  the  objective 
condition  during  the  intervals,  before  we  can  classify  the  patient 
correctly. 

The  clinical  liistory  must  be  investigated  for  all  tliose  circumstances 


THE    PROBLEM   OF   EPILEPSY  35 

which  can  point  to  the  non-surgical  character  of  the  epilepsy,  viz., 
heredity,  alcohol,  absinthe  and  lead  intoxications,  and  infections, 
especially  syphilis.  But  if  an  alcoholic  suffers  from  epilepsy,  it  must 
not  be  assumed  that  only  the  alcohol  can  be  credited  with  it,  for  it 
may  be  due  to  some  accidental  injury  to  the  skull.  Hereditary  pre- 
disposition, intoxications,  and  infections  form  the  basis  on  which 
epilepsy  develops,  when  some  exciting  factor  comes  into  play.  This 
factor  may  be  so  trifling  that  it  baffles  observation — then  the  case  is, 
and  remains  medical.  But  this  factor  may  be  provided  by  the  appre- 
ciable results  of  an  injury,  and  then  the  case  is  surgical,  in  so  far  as 
these  results  can  be  removed  by  operation. 

If  the  question  of  congenital  or  inherited  predisposition  is  disposed 
of,  we  must  first  ascertain  whether  the  patient  has  ever  sustained  an 
injury  to  the  head,  more  especially  an  injury  involving  both  the  skull 
and  the  brain.  Our  inquiries  must  be  prosecuted  even  unto  the 
patient's  birth,  because  epilepsy  may  be  the  consequence  of  a  poren- 
cephalitis due  to  injury  by  forceps. 

But,  apart  from  forceps,  childhood  offers  abundant  opportunities 
for  cranial  injuries.  If  a  child  is  not  dropped  by  its  nurse,  sooner  or 
later  it  will  fall  on  its  own  account.  The  skull  may  be  compressed 
without  the  attention  of  the  parents  being  attracted  thereto,  and  the 
brain  may  suffer  severe  damage  beneath  an  apparently  uninjured  skull 
cap.  This  damage  may,  in  its  turn,  produce  softening,  with  consequent 
cyst  formation  or  porencephalitis. 

If  it  is  clear  that  the  patient  has  sustained.an  injury  to  the  skull,  we 
must  ascertain  whether  the  epilepsy  is  a  direct  or  indirect  result.  This 
is  especially  important  from  the  point  of  view  of  accident  insurance. 
A  patient  may  have  been  epileptic  before  his  accident,  but  may  wish  to 
fasten  the  responsibility  for  his  disease  on  the  period  following  the 
injury.  But  even  if  it  transpires  that  there  has  been  a  long  interval 
between  the  injury  and  the  first  attack  of  epilepsy — years  may  have 
elapsed — we  cannot  conclude  that  the  epilepsy  is  not  traumatic.  To 
cite  one  possibility,  the  injury  may  have  caused  a  cerebral  cyst,  and 
this,  many  years  subsequently  may  declare  itself  by  means  of  epilepsy 
and  other  symptoms.  But  as  a  rule  traumatic  epilepsy  appears  within 
a  few  months  of  the  accident. 

I  once  had  a  patient  with  a  traumatic  cyst  in  the  frontal  lobe.  The 
lad  began  to  masturbate  eight  years  after  the  injury,  and  then  epilepsy 
manifested  itself  in  the  form  of  "petit  mal  "  at  first.  It  was  quite  clear 
that  the  individual  attacks  were  a  consequence  of  this  habit. 

So  far  we  have  confined  ourselves  to  injuries  of  the  head,  or,  rather, 
of  the  brain.  But  there  is  a  form  of  epilepsy  which  may  follow  any 
peripheral  irritation,  apart  from  injury  to  the  brain.  This  is  called 
rc/lcx  epilepsy.     Any  peripheral  injury  may  set  up  this  external  irritation 

3 


-^6  SURGICAL    DISEASES    OF    THE    HEAD 

and  painful  scars  over  bones,  or  those  involving  nerve-trunks  have  long 
been  credited  with  this  evil.  Even  foreign  bodies  in  the  nose  or  ear 
may  cause  epilepsy.  Demme  reports  a  case  wherein  a  rectal  polypus 
acted  in  this  way. 

When  I  was  a  student  I  saw  a  case  of  Kocher's,  in  which  typical 
Jacksonian  epilepsy  appeared  to  start  from  a  scar  in  the  hand.  The 
excision  of  the  scar  proved  useless.  It  was  then  decided  to  trephine, 
but  he  escaped  from  this  project  by  dying  suddenly.  The  autopsy 
revealed  a  well-circumscribed  tumour  in  the  situation  selected  for 
the  operation. 

Although  too  much  has  perhaps  been  attributed  to  reflex  epilepsy, 
w^e  must  not  neglect  its  consideration  when  examining  the  patient. 
Our  conjecture  will  become  a  certainty  if  the  patient  experiences  any 
abnormal  sensations  in  the  suspected  scar  before  the  attack,  or  if  we 
are  able  to  directly  excite  an  attack  by  pressing  on  the  scar. 

A  boy,  aged  3,  who  had  never  been  epileptic,  was  brought  into 
hospital  with  definite  attacks,  a  few  days  after  a  fall  on  his  forehead. 
Examination  showed  an  abrasion  of  the  forehead,  from  which  ery- 
sipelas was  spreading,  and  a  subjacent  abscess.  This  was  opened  ; 
there  was  no  fracture  of  the  skull.  The  fits  ceased  immediately,  and 
the  case,  therefore,  was  either  a  toxic  or  reflex  epilepsy. 

The  actual  observation  of  the  fit  is  an  important  part  of  the 
clinical  history.  If  it  resembles  an  ordinary  attack,  beginning  with 
general  convulsions,  and  not  regularly  affecting  any  particular  region 
of  the  body,  either  by  a  preceding  aura  or  subsequent  effects,  we  can 
draw  no  conclusion  regarding  its  etiology.  General  convulsions 
usually  signify  so-called  true  epilepsy,  i.e.,  epilepsy  with  an  unknown 
anatomical  basis,  but  they  also  occur  in  other  forms  of  epilepsy,  which 
are  caused  by  certain  gross  anatomical  changes. 

It  is  quite  different  when  the  aura,  or  the  post-epileptic  paralytic 
phenomena,  either  persistent  or  transitory,  indicate  a  definite  area  of 
the  cortex  as  the  seat  of  origin  of  the  attacks.  Two  varieties  may  be 
distinguished  in  this  connection.  In  one,  the  convulsions  are  limited 
to  a  circumscribed  motor  area,  and  we  are  therefore  confronted  with 
typical  Jacksonian  cortical  epilepsy.  In  the  other,  the  attack  similarly 
begins  in  one  definite  area,  but  it  marches,  in  anatomical  pro- 
cession, along  into  other  areas,  and  thus  the  fit  becomes  generalized. 
Temporary  paralysis  in  the  area  corresponding  to  the  seat  of  origin, 
may  follow  the  attack. 

The  relatives  can  often  furnish  useful  information  on  these  points, 
but  it  is  always  advisable  to  personally  confirm  their  statements,  or  to 
obtain  their  confirmation  from  a  hospital  trained  attendant,  because 
our  treatment  must  frequently  be  dictated  by  this  information. 

Finally,  a  careful  investigation  of  the  condition  of  the  patient 
between    the    attacks    must    be  undertaken.       Scars    on    the    scalp. 


THE    PROBLEM    OF    EPILEPSY  37 

irregularities  on  the  surface  of  the  skull,  any  trace  of  a  previous 
injury  which  might  be  seen  or  felt,  must  be  searched  for  to  complete 
the  clinical  history.  At  the  same  time  one  must  look  for  painful  scars 
anywhere  on  the  body,  for  the  reason  already  given,  and  if  the  patient 
is  a  child  suffering  from  recent  unexplained  epilepsy,  the  nose  and  ear 
must  be  examined  for  foreign  bodies. 

A  thorough  investigation  of  the  nervous  system,  with  special 
reference  to  the  motor  areas  of  known  function,  must  follow  this 
external  examination.  If  this  reveals  such  symptoms  as  paresis  of  one 
extremity,  unilateral  paralysis  of  a  cranial  nerve,  or  hemianopia,  the 
diagnosis  of  true  epilepsy  must  be  discarded,  and  the  cause  of  the 
disease  must  be  attributed  to  some  gross  anatomical  change,  viz., 
infantile  cerebral  paralysis,  old  apoplexy,  cerebral  tumour  in  its  widest 
sense,  or  cerebral  cyst. 

In  children,  the  cause  is  most  likely  to  be  an  intra-uterine  encepha- 
litis, producing  the  so-called  infantile  cerebral  paralysis.  Tumours, 
tubercle,  gummata,  traumatic  cerebral  cysts  may  occur  at  any  age,  and 
old  apoplectics  may  suffer  from  epileptic  attacks. 

It  is  only  when  an  epileptic  emerges  from  such  an  exhaustive 
investigation  without  any  flaw  that  he  must  be  regarded  as  a  case  of 
*'  genuine  epilepsy,"  and  as  far  as  our  present  knowledge  goes  surgery 
can  offer  but  little  help. 

But,  on  the  other  hand,  not  every  case  of  traumatic  epilepsy  can 
anticipate  benefit  from  operation.  Unfortunately,  experience  shows 
that  the  hopes  based  on  operative  measures  have  fallen  far  short  of 
anticipation.  This  is,  however,  not  the  place  to  discuss  this  circum- 
stance. Nevertheless,  interference  is  advisable  in  all  cases  of  traumatic 
epilepsy,  unless  the  long  duration  of  the  illness,  or  the  great  frequency 
of  the  fits,  or  the  mental  changes,  indicate  that  the  whole  central 
nervous  system  is  too  deeply  compromised.  The  prognosis  in  tubercle 
and  in  tumours  depends  upon  the  possibility  of  complete  removal  of 
the  growth.  Post-apoplectic  epilepsy  we  must  leave  to  the  physician, 
and  this  also  marks  the  limit  of  the  assistance  we  can  give  in  genuine 
epilepsy. 


SURGICAL   DISEASES   OF   THE    HEAD 


CHAPTER   VI. 

SOME  REMARKS  ON  CEREBRAL  LOCALIZATION 
AND    FOCAL  DIAGNOSIS, 

We  have  already  touched  upon  the  subject  of  focal  diagnosis — i.e., 
the  detection  of  the  situation  of  a  brain  lesion,  based  upon  our  modern 
knowledge  of  localization — but  it  is  necessary  to  return  to  it  by  a 
more  connected  method. 

Our  first  work  is  to  distinguish  a  peripheral  from  a  central  lesion 
of  the  nervous  system  ;  but,  as  we  have  seen  in  the  case  of  a  fractured 
skull  or  of  a  cerebral  tumour,  this  is  not  always  easy,  because  the  two 
lesions  may  be  present  at  the  same  time. 

Let  us  begin  with  (i)  disturbances  of  vision. 

A  glance  at  the  very  simplified  diagram  in  tig.  6  suggests  the 
various  possibilities  which  possess  surgical  interest.  Blindness  of 
one  side  indicates  an  interruption  in  the  path  between  the  retina 
and  the  chiasma  (/),  which  may  be  caused  by  primary  or  secondary 
tumours  of  the  orbit,  or  a  fractured  base.  Bitemporal  hemianopia 
is  the  classical  sign  of  a  tumour  in  the  region  of  the  chiasma 
(d),  e.g.,  a  pituitary  tumour.  Blindness  of  both  sides  depends  upon 
the  same  cause  {e),  but  it  indicates  a  later  stage  or  a  more  extensive 
lesion  {e.g.,  gunshot  with  suicidal  intent).  It  may  also  occur  when 
there  is  severe  congestion  of  the  disc  in  cases  of  chronic  cerebral 
pressure  (tumours  and  cysts  in  any  position,  but  more  especially 
in  the  posterior  cranial  fossa).  Finally,  it  may  occur  through  a 
simultaneous  lesion  of  both  cortical  visual  areas — but  this  is  rare 
(tumour  of  the  Falx  Cerebri),  Homonymous  hemianopia  indicates 
a  lesion  in  the  optic  tract  (c),  in  the  optic  radiation  (&),  in  the 
primary  visual  centres  of  the  optic  thalamus,  lateral  corpus  genicu- 
latum  and  anterior  corpus  quadrigeminum  (6^),  or  the  cerebral  cortex; 
{a),  e.g.,  tumours,  cysts,  or  trauma. 

From  the  surgical  standpoint  it  is  most  important  to  distinguish 
between  a  lesion  in  the  optic  tract  and  in  the  cortex  (see  under  Cerebral 
Tumour).  A  sign  first  described  by  Dufour  may  be  of  assistance. 
He  states  that  if  the  visual  path  be  interrupted  at  c  or  b,  the  vision  is 
dimmed  ;  if  the  lesion  be  in  the  cortex  the  vision  is  totally  absent. 
The  hemiopic  pupillary  reaction  must  be  tested  to  determine  the 
mobility  of  the  pupil.  If  no  reaction  is  obtained,  the  lesion  is  at  c, 
thus  excluding  lesions  both  at  b  and  a. 

The  cortical  lesion  is  sometimes  incomplete  {e.g.,  in  tumours).  In 
such  cases  the  hemianopia  is  also  incomplete,  there  being  merely  a 
homonymous  loss  of  one  quarter  of  the  visual  field,  which,  however, 


CEREBRAL    LOCALIZATIOX    AXD    FOCAL    DL-\GXOSIS  39 

must  not  be  confused  with  a  unilateral  scotoma  of  peripheral  origin 
There  still  remains  another  form  of  visual  disturbance,  which  requires 
brief  consideration,  although  it  rarely  possesses  surgical  interest,  as 
it  is  bilateral — i.e.,  nnind  blindness.  Whereas  the  destruction  of  the 
cortical  area  marked  {a)  in  the  diagram  prevents  the  perception  of 
visual  impressions,  these  impressions  still  arise  if  the  cortex  of  the 
cuneus  is  unaffected,  but  they  will  not  be  appreciated  by  the  mind, 
if  the  fields  for  visual  memorv  on  both  sides,  or  the  association  fibres 
leading  to  them,  are  destroved.  This  latter  condition  is  termed  "mind 
blindness,"  in  contrast  to  "  cortical  blindness,"  due  to  destruction  of 
the  cortex  of  the  cuneus  on  both  sides. 

All  these  examinations  demand  normal  intelligence  and  retained 
consciousness,  but  these  patients  frequently  possess  neither  the  one 
nor  the  other.  We  must  then  be  content  with  the  ability  to  dis- 
tinguish unilateral  blindness,  bitemporal  and  homonymous  hemi- 
anopia.  The  examination  can  be  carried  out  with  approximate 
accuracv  without  a  perimeter,  although  a  correct  visual  chart  is 
always  desirable. 

W^e  may  infer  from  the  pupil  reflexes  that  they  are  served  by  their 
own  special  fibres.  Their  behaviour  may  be  ascertained  from  the 
facts  illustrated  in  fig.  6.  Disturbances  in  the  reflexes  without  simul- 
taneous visual  disturbances  always  suggest  an  isolated  lesion  of  the 
oculomotor  nerve  or  its  nucleus. 

(2)  Derangements  of  the  extrinsic  ocular  muscles  can  only  be 
detected  by  causmg  the  patient  to  look  in  dehnite  directions,  other- 
wise thev  may  be  confused  with  conjugate  deviation.  As  soon  as  the 
patient  is  told  to  move  his  eyes,  it  will  at  once  be  seen  whether  he 
squints.  If  there  is  no  movement  of  the  eyes  when  directed  to  look 
sideways,  there  is  probably  conjugate  deviation.  Whereas  advanced 
ocular  paralysis  can  easily  be  detected,  its  slighter  forms  can  be 
concealed  by  patients  bringing  the  non-affected  muscles  into  action. 
A  very  careful  examination  for  double  vision  in  all  points  of  the  visual 
field  is  therefore  necessary.  It  has  always  been  said,  and  it  will 
subsequently  be  repeated,  that  ocular  paralyses,  except  when  they  are 
of  purely  medical  significance,  indicate  trauma,  inflammatory  diseases, 
tumours  of  the  orbit  or  base  of  the  skull,  or  affections  of  the  base  of 
the  brain.  Conjugate  deviation  on  the  other  hand,  is  always  a  sign 
of  disease  above  the  nucleus  (the  patient  looks  towards  the  healthy 
side  when  there  is  irritation,  and  towards  the  lesion  when  there  is 
paralysis).  In  this  connection,  tumours,  cysts,  abscesses  in  the  cortex, 
or  in  the  sub-cortical  white  substance,  and  also  injuiies  are  especially 
of  surgical  interest. 

The  nucleus  of  the  sixth  nerve  forms  an  exception  to  what  has 
just  been  said.     According  to  the  most  recent  researches,  this  nucleus 


40 


SURGICAL   DISEASES    OF   THE    HEAD 


represents  a  more  deeply  situated  co-ordination  centre.  Injury 
thereof,  which  hardly  possesses  any  surgical  significance,  leads  to 
conjugate  deviation  towards  the  healthy  (opposite)  side. 

In    addition    to     conjugate    deviation,    S'ystng^iiiis    must    also    be 


a.  Cortical  lesion 
(cuneus,  trauma, 
tumour,  cyst, 
abscess).  Homo- 
nymous crossed 
hemiatiopia  (loss 
of  opposite  visual 
fields).  Absence 
of  vision  com- 
plete. Reflexes 
normal. 

i.  Lesion  of  optic 
radiation,  or  of 
primary  visual 
centres(i5').  Causes 
as  above.  Sym- 
ptoms as  in  a,  but 
vision  dimmed. 

<r.  Lesion  of  optic 
tract  (generally 
tumour).  Same 
symptoms  as  i, 
and  d',  but  pupil 
reflexes  from  op- 
posite visual  fields 
lost  (hemiopic  pu- 
pillary reaction). 

(/.  Partial  lesion  of 
chiasma  (pituitary 
tumour).  Loss  of 
both  temporal 
visual  fields  (bi- 
temporal bemian- 
opia).  C  o  r  r  e- 
sponding  loss  of 
pupillary  reflexes. 

c.  Complete  lesion  of 
chiasma  (tumour, 
traumatism,  espe- 
cially suicidal 
jjunshot  wounds). 
Blindness  of  both 
sides,  and  com- 
plete loss  of  pupil- 
lary reflexes. 

/.  Lesion  of  optic 
nerve  (trauma,  tu- 
mour). Unilateral 
blindness,  with 
loss  of  reflex  on 
the  diseased  side, 
and  of  consensual 
contraction  on 
healthy  side.  If 
lesion  is  incom- 
plete, unilateral 
scotoma,  or  con- 
centric contrac- 
tion of  visual  field. 


Fig.  6.— Diagram  of  the  principal  surgical  disturbances  of  vision.       Red  and  blue  =  visual 
fibres.     Black  =  pupillary  fibres.       Ill  is  placed  opposite  oculomotor  nucleus. 


mentioned  as  a  symptom  of  irritation.  This  may  be  excited  artificially 
through  the  vestibular  nerve,  by  injecting  cold  or  hot  water  into  the 
ear.     This  symptom  is  frequently  associated  with  damage  to  the  nerve 


cerp:bral  localization  and  focal  diagnosis 


4^ 


itself,  and  also  with  tumours  in  the  neighbourhood  of  the  cerebellum. 
It  is  obviously  also  present  in  diseases  in  the  vicinity  of  the  nuclei  of 
the  ocular  muscles. 

(3)   It  is  most  important  to  understand  that  in  a  peripheral  injury 


.  Cortical  lesion  (trauma, 
tumour,  cyst,  abscess). 
Crossed  total  paralysis 
of  facial  distribution  to 
lower  region  of  face  ; 
partial  paralysis  of  upper 
region  of  face.  Taste  and 
salivary  fibres  normal. 
Corneal  reflex  retained. 
Stapedius  not  paralysed. 
No  reaction  of  degenera- 
tion. 

b.  Lesion  of  internal  capsule 
(causes  as  above).  Same 
symptoms,  but  movements 
of  expression  retained. 

c.  Lesion  at  exit  of  7th  N.  root 
(fractured  skull).  Paralysis 
of  all  motor,  lachrymal 
and  salivary  fibres  on  same 
side.  Stapedius  paralysed 
(hyperacusis).  Corneal 
reflex  lost.  Taste  fibres 
unaffected.  Expression 
and  associated  movements 
paralysed.  R.A.  more  or 
less  pronounced. 

d.  Lesion  in  petrous  bone, 
below  geniculate  ganglion 
(fractured  skull,  mastoid 
osteitis).  Complete  motor 
paralysis  on  same  side. 
Hyperacusis.  Salivary 
and  taste  fibres  paralysed, 
lachrymation  normal. 
Expression  and  associated 
movements  paralysed. 
Corneal  reflex  lost.  R.A. 
as  above. 

e.  Lesion  below  offshoot  of 
N.  to  stapedius  (same 
causes).  Same  sj'mptoms, 
except  that  stapedius  is 
not  paralysed. 

f.  Lesion  at  stylo-mastoid 
foramen  (trauma,  new 
growths).  Same  symptoms, 
but  taste  and  salivary 
fibres  unaffected. 


Fig.  7.  — Diagram  of  injuries  to  facial  nerve.     Red  =  motor  fibres.     Green  =  salivary 

fibres.     Blue  =:  taste  fibres. 


of  the  facial  nerve  (see  fig.  7),  all  the  branches  to  the  face  are  equally 
involved;  but  when  the  lesion  is  central,  the  lower  facial  branches 
sutler  most,  because  the  branch  to  the  forehead  is  innervated  from 
both  sides  of  the  brain.     It  must  also  be  remembered  that  peripheral 


42 


SURGICAL    DISEASES    OF   THE    HEAD 


paralysis  is  on  the  same  side  as  the  injury,  whereas  a  central  lesion 
produces  paralysis  on  the  opposite  side.  This  distinction  is  valuable 
when  we  know  the  situation  of  the  injury  to  the  skull,  but  discrimina- 


suleus  cenircdis 


su(cus   uitEr- 
etalis 


fissura  csrebn 
lateralis  (Sylv'd) 

gyrus  suJjcaUo&u.i-'' 


gyrus  temporaUS 
infefLor 


Fig.  8 — The  most  important  cortical  areas,  as  at  present  established.  Red  =  motor  area. 
Dotted  red  =  motor  speech  centre.  Blue  =  sensory  area.  Green  =  auditory  area.  Dottedgreen  = 
sensory  speech  centre.     Yellow  =  visual  area. 


CEREBRAL   LOCALIZATION   AND    FOCAL   DIAGNOSIS 


43 


tion  must  be  exercised,  because  in  cases  of  injury  to  the  cortex  by 
contrecoup,  the  paralysis  is  on  the  same  side  as  the  injury.  Signs  of 
irritation,  convulsions  in  the  paralysed  region,  as  well  as  paralysis 
of  the  limbs  on  the  same  side,  denote  a  central  lesion.  Definite 
conclusions  may  also  be  drawn  from  the  varying  conditions  of 
voluntary  movement,  associated  movements,  and  those  of  facial  ex- 
pression. If  these  last  are  retained,  and  at  the  same  time  associated, 
and  voluntary  movements  are  completely  lost,  it  is  quite  certain  that 

S 


Fig.  9.— Determination  of  cortical  centres  after  Kocher.      Centres  filled  in  partially 

after   Krause. 

the  lesion  is  central.  But  we  can  infer  nothing  from  the  predomin- 
ance of  the  vohmtary  over  the  associated  movements,  because  this 
peculiarity  may  be  present  in  a  central  as  well  as  in  a  peripheral 
paralysis  (Sahli).  Paralysis  of  the  secretory  and  taste  fibres  of  the  facial 
nerve,  shown  by  ;i  decrease  of  saliva  and  by  diminution  on  the 
corresponding  half  of  the  tongue  of  taste  appreciated  by  the  fifth 
nerve,  is  only  of  limited  diagnostic  value.     Motor  paralysis  due  to  a 


44 


SURGICAL    DISEASES    OF  THE    HEAD 


lesion  between  the  nucleus  and  the  geniculate  ganglion,  really  at  the 
base  of  the  brain  (fig.  7  c),  is  accompanied  by  taste  disturbance  only; 
but  lesions  in  the  petrous  bone  (fig.  7  d,  and  c),  below  the  geniculate 
ganglion  cause  taste  disturbance  and  also  a  diminution  of  salivary 
secretion  ;  disturbance  of  lachrymation  is  only  caused  by  damage 
above  the  geniculate  ganglion. 

The  presence  of  these  defects,  therefore,  excludes  a  cortical  lesion, 
but  their  absence  only  excludes  such  a  lesion  when  the  upper  as  well 
as  the  lower  branches  of  the  facial  are  simultaneously  affected. 

These  delicate  in- 
vestigations demand  a 
good  deal  of  time,  and 
also  require  a  due 
amount  of  intelligence 
the     part    of     the 


on 


patient.  It  is  only  ex- 
ceptionally, as  in  the 
case-  of  growths,  and 
the  results  of  injury, 
that  the  requisite  time 
is  devoted  to  the  ex- 
amination ;  but  if  we 
have  to  decide  quickly, 
whether  and  where  we 
should  trephine  an  un- 
conscious patient,  the 
previously  noted  signs 
must  guide  us.  They 
may  be  summarized 
thus  :  A  central  lesion 
is  indicated  (i)  when 
the  eyes  and  the  frontal 
branches  are  compara- 
tively unaffected  ;  (2) 
when  there  is  an  opposite 
paralysis  after  an  injury  ;  or  (3)  when  the  limbs  are  paralysed  on  the 
same  side.  A  peripheral  lesion  is  indicated  (i)  when  all  the  branches 
are  affected  on  the  same  side  as  the  injury  to  the  skull ;  (2)  when  ocular 
paralyses  are  also  present,  pointing  to  injury  of  the  petrous  bone.  If 
there  be  paralysis  of  the  limbs  on  the  side  opposite  to  the  facial  palsy,  the 
lesion  is  at  the  base,  in  the  neighbourhood  of  the  pons,  or  there  may  be 
two  separate  foci  of  disease. 

(4)  The  auditory  nerve  also   possesses   many  points  of   surgical 
interest. 


Fig.  10. — Base  of  brain  (adapted  from  Henle). 


CEREBRAL    LOCALIZATION    AND    FOCAL    DIAGNOSIS  45 

(a)  Disturbance  of  the  function  of  the  cochlear  nerve — which  is 
the  essential  nerve  of  hearing — may  be  due  to  pathological  changes 
at  the  base  of  the  skull  or  at  the  base  of  the  brain — injury,  inflamma- 
tion or  tumour.  We  are  able  to  decide,  by  means  of  Rinne's  and  of 
Weber's  tests,  whether  the  nerv^e  itself  or  the  sound-conducting 
apparatus  is  involved.  If  Rinne's  test  is  positive,  i.e.,  if  air  conduc- 
tion is  better  than  bone  conduction,  and  if  Weber's  test  shows  that 
the  note  of  the  tuning  fork  placed  on  the  vertex  appears  louder  in  the 
injured  ear  than  in  the  other  one,  we  mav  assume  that  the  disease  is 
in  the  nerve  structures.  We  cannot,  however,  tell  whether  the  nerve 
itself  is  affected  in  its  course,  or  the  end  organ  or  the  cochlea.  Even 
the  loss  of  nigh  pitched  notes  (Galton's  whistle)  only  indicates  that 
the  damage  is  in  the  nerve  apparatus,  but  gives  no  information  regard- 
ing its  position.  There  is  always  some  uncertainty  as  to  the  significance 
of  auditory  disturbances.  A  definite  significance  is  onl}^  possible  if 
the  patient's  hearing  was  normal  before  the  onset  of  the  disease  from 
which  he  is  suffering,  but  in  many  cases  this  cannot  be  ascertained. 

(6)  The  vestibular  nerve  is  of  more  importance,  surgically,  although 
damage  to  it  cannot  be  distinguished  from  damage  to  the  end-organ 
(semi-circular  canals) — or,  rather,  can  only  be  distinguished  from  it 
indirectly.  As  the  vestibular  nerve  is  responsible  for  maintaining  the 
equilibrium,  the  characteristic  symptom  of  its  injury  is  lo^s  of 
equilibrium,  appreciated  by  the  patient  as  giddiness  — indeed,  as 
rotatory  giddiness.  But  as  the  fibres  of  the  vestibular  nerve  terminate 
in  the  cortex  of  the  cerebellum,  and  especially  in  the  vermiform 
process,  it  follows  that  injuries  or  diseases  of  the  cerebellum  produce 
the  same  symptoms  of  giddiness.  According  to  English  authorities, 
the  difference  between  central  and  peripheral  disturbances  of  the 
equilibrium  apparatus  is  to  be  found  in  the  fact,  that  when  the  dis- 
turbance is  peripheral,  external  objects  appear  to  the  patient  to  be 
rotating  from  the  healthy  to  the  diseased  side,  whereas  in  central 
disturbances  the  rotation  is  from  the  diseased  to  the  healtiiy  side. 

(5)  We  will  not  discuss  the  special  circumstances  attending  those 
cranial  nerves  which  are  not  referred  to  here,  because  all  the  important 
diagnostic  points  have  been  mentioned  in  their  appropriate  place. 

(6)  When  there  is  paralysis  of  other  movements,  especially  in  the 
extremities,  the  main  surgical  mterest  refers  to  the  question  whether 
the  lesion  is  in  the  cortex  or  at  the  base.  This  must  be  decided  by 
observing  what  concomitant  symptoms  are  present,  as  previously 
indicated.  There  is  not  usually  any  difficulty  in  this,  because  a  facial 
palsy  on  the  same  side  will  point  to  a  cortical  lesion,  whereas  opposite 
paralysis  of  the  facial,  trigeminal,  abducens  or  auditory  nerves  will 
point  either  to  a  basal  lesion  or  to  two  separate  foci  of  disease. 

F'igs.  8  and  9  represent  all  the  points  hitherto  established. 


46 


SURGICAL   DISEASES   OF   THE    HEAD 


(7)  Aphasia  can  be  diagnosed  by  the  well-known  general  rules. 
Its  surgical  significance  is,  however,  small,  whether  we  adopt  the  usual 
view  of  a  definite  cortical  centre,  or  attribute  the  so-called  cortical 
motor  aphasia  to  disease  of  sub-cortical  tracts. 

V.  Monakow  has  recently  endeavoured  to  explain  certain  conditions 
which  do  not  accord  with  the  usual  scheme,  by  assuming  that  one 
cortical  area  may  exert  an  inhibiting  effect  on  another  (Diaschisis). 

The  restoration  of  the  power  of  speech  after  destruction  of  the 
corresponding  cortical  convolution  on  the  left  side,  may,  on  this 
theory,    not    be    due   to    the    corresponding   area    on    the   right   side 

gradually  taking  up 
this  duty,  but  may  be 
explained  by  the  cess- 
ation of  the  diaschisis. 
It  is  important  to 
distinguish  between 
anarthria  and  aphasia. 
A  narthria  means 
"  word  mutilation," 
the  result  of  damage 
to  the  peripheral 
speech  apparatus  (dis- 
turbance of  function 
in  the  vicinity  of  the 
nuclei  and  the  emerg- 
ing roots).  Aphasia, 
on  the  other  hand, 
means  a  derangement 
in  the  power  of  "  word 
construction "  in  the 
region  of  the  cortex 
and  the  subcortical 
association  fibres. 
Anarthria  points  to 
tumours  in  the  neigh- 
bourhood of  the  pons  and  the  medulla  oblongata,  whereas  aphasia 
indicates  damage  to  the  cortical  centres  and  the  subcortical  fibres. 
It  is  easy  enough  to  differentiate  in  the  extreme  cases,  but  difficulty 
arises  in  the  mild  cases,  because,  in  slight  cortical  and  subcortical 
changes,  especially  when  the  interruption  of  the  speech  fibres  is  in- 
complete, disturbances  arise  which  are  hardly  distinguishable  from 
nuclear  and  peripheral  anarthria.  A  correct  diagnosis  can  only  be 
made  in  such  cases  by  taking  other  symptoms  into  consideration 
(those  arising  from  the  pons,  medulla,  or  other  cortical  symptoms). 
It  should  be  added  that  the  speech  centre  is  usually  on  the  right 
side  in  left-handed  people. 


Fig,  II. — Nerves  at  the  base  of  the  skull  (adapted  from  Henle). 


CEREBRAL    LOCALIZATION    AND    FOCAL   DIAGNOSIS 


47 


The  study  of  aphasia  has  established  the  following  points  in  regard 
to  the  surgical  aspect  of  local  diagnosis  : — 

(i)  Definite  pure  anarthria  indicates  a  lesion  in  the  cerebral 
peduncle,  pons,  or  medulla  oblongata. 

(2)  If  the  differentiation  between  anarthria  and  aphasia  is  not  quite 
clear,  the  remaining  physical  conditions  will  enable  the  diagnosis  to 
be  made. 

(3)  Definite  motor  aphasia  indicates  a  lesion  in  Broca's  convolution 
(inferior  frontal  convolution). 

(4)  Definite  sensory  aphasia  indicates  a  lesion  in  Wernicke's  con- 
volution (superior  temporal  convolution). 


Fig.  12. — Simplified  method  of  defining 
precentral  sulcus. 


Fig.  13. 


-Simplified  method  of  defining 
precentral  sulcus. 


Numerous  methods  and  instruments  have  been  devised  for  defining 
the  cortical  areas  on  the  surface  of  the  skull.  We  shall  here  only  refer  to 
the  useful  and  practical  methods  of  Kocher  and  Kroenlein.  The  whole 
procedure  is  greatly  simplified  by  employing  the  special  craniometer 
invented  for  the  purpose  ;  but  a  tape  measure  and  a  blue  pencil  will 
do  quite  well.  The  most  important  thing  is  to  define  the  anterior  central 
convolution,  wherein  the  chief  motor  centres  lie.  This  convolution  lies 
between  the  central  and  precentral  sulcus.  Kocher's  method  depends 
upon  the  simple  and  certain  definition  of  this  latter  landmark. 
4 


48 


SURGICAL   DISEASES    OF  THE    HEAD 


The  base  line  is  first  drawn,  by  placing  the  tape  measure  horizon- 
tally just  above  the  concha,  and  through  the  glabella  and  external 
occipital  protuberance.  The  lower  border  of  the  tape  measure,  fixed 
in  this  position,  is  marked  off  with  the  blue  pencil  (figs.  12  and  13). 
The  sagittal  nieridian  is  defined  in  a  similar  manner,  by  placing  the 
tape  over  the  vertex,  from  the  glabella  to  the  external  occipital  pro- 
tuberance (N.  S.  O.,  figs.  8,  12,  13).  The  length  of  this  line  is 
measured  (in  adults,  about  35  cm.),  and  its  mid-point  is  marked  on 
the  vertex,  i.e.,  17^  cm.  from  either  end  (S.  point  of  vertex).  A  second 
meridian  must  now  be  defined,  with  the  craniometer,  which  should 
meet  the  saggital  meridian  at  an  angle  of  60°.  This  meridian  can 
be   ascertained,  wdthin    2    or   3    degrees  of   perfect   accuracy,  in  the 

followmg  manner.  One  half 
of  the  base  line  is  divided  into 
three  equal  parts,  and  the  tape 
is  placed  with  one  end  on  the 
hinder  point  of  the  first  division 
f,  and  the  other  end  on  the 
point  of  the  vertex  S.  (In 
adults  the  point  c  is  9  to  9^ 
cm.  behind  the  glabella).  The 
meridian  so  obtained  defines 
the  position  of  the  precentral 
sulcus  (Pr.)  behind  which  the 
chief  centres  are  to  be  sought 
for.^  If  this  meridian  be  divided 
into  three  equal  parts,  the  lower 
points  of  the  two  upper  divisions 
(rt  and  b)  will  correspond  to 
the  hinder  extremity  of  the  two 
frontal  sulci.  The  upper  third 
w^ill  indicate  the  leg  centres, 
the  middle  third  the  arm 
centres,  and  the  lower  third 
the  face  centres.  In  order  to 
define  the  fissure  of  Sylvius 
the  tape  is  applied  from  the 
root  of  the  nose  to  the  upper  end  of  the  squamous  portion  of  the 
temporal  bone,  at  the  beginning  of  the  lamboid  suture.  The  portion 
of  this  line,  behind  the  precentral  sulcus,  corresponds  in  its  w^hole 
extent  to  the  Sylvian  fissure. 

Other  topographical  areas  ascertained  by  means  of  these  funda- 
mental lines  are  indicated  in  figs.  8  and  9,  which  are  partially  based 
on  the  latest  w^ork  of  Krause. 

^  Kocher's  precentral  line  obtained  by  angle  measurement  lies  further  behind. 
It  can  be  obtained  by  moving  the  point  c,  h  cm.  posteriorly.  There  will  then  be 
a  difference  of  i^  to  2  mm.  in  the  point,  making  the  hinder  extremity  of  the  superior 
frontal  sulcus,  and  a  difference  of  3  to  4  mm.  in  the  point,  making  hinder  extremity 
of  the  inferior  frontal  sulcus.  But  I  have  frequently  demonstrated  on  the  cadaver 
that,  as  all  these  methods  possess  inevitable  errors,  this  difference  is  of  no  essential 
consequence 


Fig.  14. — Craniometry  (after  Kroenlein). 


THE  SURGERY  OF  EXOPHTHALMOS 


49 


Kroenlein's  method  of  measurement  is  particularly  useful  in  the 
search  for  a  haimatoma  of  the  middle  meningeal  artery,  or  for  abscesses 
of  brain,  due  to  ear  disease. 

The  base  line  is  determined  by  means  of  tape-measure  and  blue 
pencil  ;  the  tape  being  placed  at  the  level  of  the  infra-orbital  margin 
and  the  external  auditory  meatus.  A  superior  horizontal  line  is  marked 
off,  parallel  with  this,  at  the  level  of  the  supra-orbital  margin.  Three 
perpendicular  lines  are  then  drawn  in  the  following  positions :  (i) 
anterior,  through  the  middle  of  the  zygomatic  arch  ;  (2)  middle, 
through  the  condyle  of  the  lower  jaw  ;  (3)  posterior,  through  the  hind- 
most point  of  the  base  of  the  mastoid  process.  By  joining  the  point 
where  the  anterior  perpendicular  line  intersects  the  superior  horizontal, 
with  the  point  at  which  the  posterior  perpendicular  intersects  the  line 
of  the  vertex  of  the  head,  we  then  get  a  line  which  corresponds  to  the 
fissure  of  Rolands.  By  bisecting  the  angle  made  between  this  line 
and  the  superior  horizontal,  we  obtain  the  direction  of  the  fissure  of 
Sylvius.  The  points  K  and  K'  (tig.  14)  indicate  Kroenlein's  landmarks 
for  trephining  in  cases  of  hasmatoma  of  the  middle  meningeal  artery. 
The  square  A  B  K'  M  is  the  area  suggested  by  Bergmann  for  searching 
for  cerebral  abscess  of  aural  origin. 


CHAPTER    VII. 
THE   SURGERY   OF   EXOPHTHALMOS. 

A  STARING  eye  always  calls  for  an  answer  to  the  cjuestion  whether 
it  is  a  real  enlargement  of  the  organ,  a  bnplithahnos,  or  a  protrusion  of 
the  organ — an  exopiithaUnos.  The  former  has  a  certain  amount  of 
surgical  interest  when  it  is  caused  by  a  tumour,  a  sarcoma  of  the 
choroid  or  glioma  of  the  retina.  But  as  these  growths  concern 
the  speciality  of  ophthahnology,  which,  however,  gains  very  little 
credit  from,  them,  we  shall  here  limit  ourselves  to  the  discussion  of 
exophtliahnos. 

If  a  bilateral  exophthalmos  has  come  on  gradually  during  a  course 
of  months  or  even  years,  and  if  it  is  accompanied  by  tachycardia  and 
tremors,  we  may  at  once  diagnose  Graves's  disease,  which  will  be  fully 
discussed  in  the  section  on  Swellings  of  the  Neck. 

If  a  unilateral  exophthalmos  has  come  on  in  the  course  of  weeks 
or  months,  and  is  accompanied  by  double  vision,  the  cause  is  either 


50  SURGICAL    DISEASES    OF   THE    HEAD 

a  tumour  developing  within  the  orbit,  or  one  invading  it  from  with- 
out, starting  from  the  base  of  the  skull  or  the  upper  jaw — usually  a 
sarcoma.  If  the  symptoms  have  been  slow  in  manifesting  themselves, 
we  should  think  of  an  innocent  growth,  viz.,  an  ivory  osteoma  of  the 
orbital  bones,  or  a  fibroma  of  the  base  of  the  skull  penetrating  the 
orbit. 

A  unilateral  exophtJiahnos  which  has  come  on  gradually  after  an 
injury,  and  which  is  accompanied  by  pulsation  of  the  eyeball,  and  by 
a  buzzing  noise  synchronous  with  the  carotid  pulse,  heard  with  the 
stethoscope  in  the  temporal  region,  represents  the  clinical  picture  of 
what  may  be  briefly  called  a  pulsating  exophthalmos.  This  is  caused 
by  a  rupture  of  the  internal  carotid  artery  into  the  cavernous  sinus, 
and  it  is  impossible  to  confuse  this  condition  with  any  other.  But  if 
confirmatory  signs  are  required,  these  may  be  found  in  the  dilatation 
of  all  the  ocular  and  conjunctival  vessels,  in  the  congested  disc,  in  the 
progressive  loss  of  sight,  and  in  the  gradual  onset  of  paralysis  of  the 
sixth  nerve. 

Any  injury  involving  the  neighbourhood  of  the  cavernous  sinus 
may  produce  this  condition.  A  fractured  base  is  the  most  frequent 
cause,  but  stabbing  and  shooting  injuries  are  occasionally  responsible. 
The  same  clinical  picture  sometimes  arises  quite  spontaneously,  with- 
out any  injury,  and  is  then  due  to  aneurysm  of  tlie  oplithalniic  artery,  or 
a  cavernous  angioma  of  the  orbit,  in  which  latter  the  pulsation  is  not 
well  marked.  Finally,  exophthalmos  pulsans  has  also  been  noted  as 
a  consequence  of  venous  congestion,  due  to  severe  pressure  during 
birth. 

In  determining  the  etiology,  it  is  important  to  realize  that  the 
symptoms  may  not  appear  for  months  or  even  years  after  the  injury. 

An  acute  exophthalmos,  either  unilateral  or  bilateral,  generally 
depends  upon  a  retrobulbar  haemorrhage,  usually  the  result  of  a 
fractured  base,  but  not  necessarily  so.  The  presence  of  suffused  lids, 
either  immediately,  or  coming  on  after  a  day  or  two,  is  a  further 
indication  of  the  cause  at  work. 

If  all  these  causes  are  absent,  there  remains  only  some  inflamma- 
tory process  to  be  considered,  either  a  retrobulbar  thrombosis  or 
abscess.  The  differential  diagnosis  of  these  two  conditions  will  be 
detailed  later  on. 


SWELLINGS    ON   THE    HEAD  51 


CHAPTER   VIII. 

ACUTE    INFLAMMATORY    PROCESSES    ON   THE 

SKULL. 

Apart  from  erysipelas,  which  is  usually  a  secondary  affection 
of  the  scalp,  and  which  is  peculiar  in  the  absence  of  reddening  of 
the  skin,  the  acute  inflammations  concern  the  glands  or  the  bones. 
Inflamed  glands  will  be  found  behind  the  ear,  or  in  the  posterior 
cervical  region.  The  portal  of  infection  is  generally  a  slight  super- 
ficial abrasion  or  a  moist  eczema,  and  there  is  never  any  difficulty 
about  the  diagnosis.  Infections  of  the  bones  are,  however,  not  quite 
so  simple.  If  the  inflammatory  process  is  situated  behind  the  ear,  a 
purulent  otitis  should  be  sought  for,  and  it  will  generally  be  found. 
It  very  rarely  happens  that  the  infection  misses  the  middle  ear,  and 
settles  forthwith  in  the  cells  of  the  mastoid  process.  In  these  rare 
cases,  however,  it  will  be  possible  to  trace  a  previous  sore  throat  or 
influenza,  &c.  If  the  inflammatory  process  is  located  elsewhere,  we 
must  resort  to  the  diagnosis  of  acute  periostitis  and  osteomyelitis 
of  the  skull.  This  diagnosis  is  easily  made  if  the  infection  of  the 
cranial  bones  represents  a  metastasis  from  a  distant  focus  of  osteo- 
myelitis elsewhere.  But  if  this  is  not  the  case  we  must  recognize 
in  these  symptoms  a  primary  osteomyelitis  of  the  skull,  although 
this  is  a  rare  condition.  It  is  important  to  make  an  early  diagnosis, 
because  if  operation  is  delayed,  there  is  the  dnnger  resulting  from  the 
suppuration  advancing  to  the  inner  table  of  the  skull  bone. 


CHAPTER    IX. 
SWELLINGS    ON   THE   HEAD. 

Our  first  inquiry  concerning  any  swelling  on  the  head  should  be 
to  ascertam  whether  it  is  congenital.  If  it  be  so,  the  diagnosis  is 
either  :  (i)  Cerebral  Jicniia,  (2)  Hernia  of  the  nieniiiges,  (3)  Angioma,  or 
(4)  Dcinwid.  Other  congenital  swellings  are  very  rare,  and  are 
generally  connected  with  a  concealed  cephalocele. 

/J.— CONGENITAL   SWELLINGS    OF   THE   HEAD. 

(i)  Cerebral  herniae  are  situated  in  the  middle  line,  mostly  above 
the  nose,  or  on  the  occipni. 


5^ 


SURGICAL   DISEASES   OF   THE    HEAD 


Cerebral  herniae  at  the  base  are  very  rare  and  do  not  possess  any 
surgical  interest. 

Cerebral  herniae  on  the  forehead  form  moderately  large,  flat,  semi- 
circular, or  sometimes 
irregular  swellings,  and 
they  chiefly  contain  brain 
substance  ;  hence  their 
name  of  eiicepJialoceles. 
Cerebral  herniae  at  the 
hack  of  the  neck  are  much 
larger.  They,  contain 
either  a  dilated  posterior 
cornu  surrounded  by  a 
thin  layer  of  brain  sub- 
stan  ce,  or  a  very  dilated  reti- 
form  arachnoideal  space 
with  a  plug  of  brain  sub- 
stanceat  its  base  (d//ce'/)//rt/o- 
iiieniiigocele).  Asimple  pro- 
trusion of  the  meninges, 
a  pure  tncningocele,  is  a 
much  rarer  condition. 


Fig.  15. — Superior  occipital  encephalomeningocele 
(with  a  vascular  naevus  in  the  region  of  the  cerebral 
hernia). 


Many  cases  which  were  previously  regarded  as  pure  meningoceles 
are  really  encephalomeningoceles  of  one  of  the  previously  mentioned 

types.     Sometimes   a  mi- 
f  ;     croscopic   examination    is 

necessary  before  the  real 
nature  of  the  deformity 
can  be  determined. 

Superior  (fig.  15)  and 
inferior  occipital  cerebral 
hernia  (fig.  16)  are  dis- 
tinguished according  to 
their  position,  above  or 
below  the  occipital  pro- 
tuberance. 

Whenever  these  swell- 
ings become  more  tense 
on  crying,  it  signifies  a 
communication  with  the 
interior  of  the  skull.  The 
same  applies  to  pulsation, 
which,  however,  is  often  absent  in  the  case  of  cystic  hernia  of  the 
brain.     Displacement  on  steady  pressure    occurs  with  meningoceles 


Fig.   16. — Inferior  occipital  encephalomeningocele. 


SWELLINGS   ON   THE    HEAD 


53 


and  cystic  encephaloceles.  This  depends  upon  the  extent  of  the 
connection  with  the  interior  of  the  skull,  and  it  is  obvious  that  in 
large  swellings  the  displacement  is  very  imperfect.  It  is  not  always 
possible  to  detect  the  hernial  aperture,  i.e.,  the  gap  in  the  skull,  which 
may  be  quite  small,  even  when  the  swelling  is  large.  We  sometimes 
find,  especially  in  large  meningoceles,  that  an  incipient  liydroccphahis 
is  present,  which  it  is  most  important  to  recognize,  because  this  com- 
plication excludes  the  possibility  of  a  successful  operation. 

These  congenital  swellings  must  be  diagnosed  from  : — 

(a)  H^emorrhagic  cyst  of  a  sinus,  the  so-called  Siiiiis  pericmiiiiis. 
This  swelling  emanates  from  within  the  skull,  it  is  situated  in  the 
middle  line,  generally  on  the  occiput,  but  it  contains  blood  instead 
of  cerebrospinal  fluid.  If  the  swelling  is  large,  and  the  overlying 
skin  is  thin,  the  dark  blue  blood 
will  be  visible  through  it  ;  but  if 
the  swelling  is  small,  and  the  over- 
lying skin  has  not  been  thinned 
out,  we  shall  get  no  assistance 
from  the  colour.  But  in  these 
cases,  the  swellings  are  very  easily 
emptied  by  pressure,  because  the 
cerebral  sinuses  have  many  more 
outlets  than  the  subarachnoid 
spaces. 

(6)  Cavernous  angioma  which 
has  formed  a  secondary  com- 
munication with  the  longitudinal 
sinus,  as  seen  particularly  at  the 
anterior  fontanelle.  It  is  easier 
to  displace  the  contents  of  this 
swelling  than  a  cerebral  hernia, 
and  the  cavernous  structure  of 
the  swelling    can    be    i-ecognized 

through  the  skin.  Furthermore,  cephaloceles  at  the  anterior  fontanelle 
are  so  rare  that  their  existence  has  been  recently  denied. 

(c)  Dermoid. — In  this  case  there  are  no  signs  of  communication 
with  the  interior  of  the  skull,  unless  the  dermoid  is  situated  in  a  gap 
of  the  skull  and  presses  directly  on  the  dura  mater,  as  in  the  patient 
depicted  in  fig.  17.  But  even  in  this  last  type  of  case  the  symptoms 
noted  are  very  much  less  definite  than  in  cerebral  hernia. 

If  a  child  presents  a  pulsating,  displaceable,  dome-shaped  swelhng 
of  the  integument  of  the  head,  not  necessarily  in  the  middle  line, 
accompanied  bv  more  or  less  evident  defect  of  the  bone,  it  must  be 
regarded  as  a  spurious  meningocele  due  to  some  previous  injury — 


Fig.  17. — Dermoid  cyst,  situated  in  a  gap  of 
the  skull. 


54 


SURGICAL   DISEASES   OF   THE    HEAD 


a  traumatic  cephalo-hydrocele.  This  may  be  caused  when  a  child 
has  sustained  an  injury  to  the  skull  with  contusion  of  the  brain,  and 
a  communication  has  formed  between  the  subcutaneous  tissue  and 
one  of  the  cerebral  ventricles.  The  condition  is  really  a  traumatic 
porencephaly,  complicated  with  an  effusion  of  cerebrospinal  fluid 
under  the  skin.  The  injury  may  have  been  inflicted  at  birth,  with 
the  forceps,  when  it  will  be  regarded  as  congenital,  or  it  may  have 
been  caused  by  a  blow^  or  a  fall ;  not  unfrequentiy  by  dropping  the 
child.  If  the  ciiild  is  rickety  the  defect  in  the  skull  may  gradually 
increase,  and  therewith  also  the  effusion  of  the  fluid  under  the  skin. 
In  cases  of  forceps  injury  we  have  seen  the  condition  subside  com- 
pletely. The  swelling  gradually  disappears  in  the  course  of  a  year, 
and  is  only  apparent    if   the  head  is  in  a   dependent  position,   and 

eventually  the  aperture  is  entirely 
filled  in  by  dense  fibrous  tissue. 
Its  characteristics  are,  therefore, 
quite  definite  in  every  stage.  If 
the  injury  has  involved  the  motor 
area,  an  incurable  spastic  hemi- 
paresis  will  follow,  corresponding 
completely  to  the  clinical  picture  of 
a  cerebral  infantile  paralysis.  The 
examination  of  the  opposite  half  of 
the  head  should,  therefore,  never  be 
neglected  in  this  variety  of  paralysis. 
Traumatic  meningoceles  not 
communicating  with  the  lateral 
ventricle  are  very  rarely  met  wath. 
They  are  small  and  are  only  re- 
placeable with  difficulty. 

(2)  We  have  mentioned  angioma 
as  the  second  variety  of  congenital 
swelling.  All  grades  of  this  variety  exist,  from  teleangiectatic  stains, 
which  scarcely  project  above  the  skin,  to  large  cavernous  angio- 
mata.  They  may  occur  anywhere  on  the  skull,  and  the  fact  that 
they  are  freely  movable  over  the  bone  shows  that  they  are  situated 
in  the  skin.  Their  finely  nodular  surface  (fig.  18)  and  the  hue  of  the 
blood  visible  through  them  as  a  red  or  blue  colour,  permits  of  the 
framing  of  an  immediate  diagnosis.  We  have  already  seen  that  a 
cavernous  angioma  can  penetrate  deeply  and  open  into  a  sinus. 

(3)  Dermoids  are  situated  under  the  skin,  generally  in  the  orbital 
region,  more  rarely  at  the  back  of  the  neck,  but  very  rarely  on  the 
vertex.  They  are  but  slightly  movable  over  the  bone,  and  are  often 
situated    in    a    depression    thereof,    occasionally    even    infiltrating   it. 


Fig.    18. — Mulberry-shaped  angioma 
in  an  infant. 


SWELLINGS   ON   THE    HEAD 


55 


They  can  frequently  be  detected  in  children,  but  as  a  rule,  they  only 
develop  in  later  life  to  a  size  which  is  noticeable  (figs.  24  and  25). 

(4)  Atheromata  (Sebaceous  cysts)  should  also  be  mentioned  in 
this  connection.  Although  these  probably  develop  from  some  con- 
genital antecedents  they 


are  not  usually  evident 
until  after  the  age  of 
20  or  more,  appearing 
anywhere  on  the  skull, 
sometimes  even  in  crops 
of  dozens.  They  vary 
in  size  from  a  lentil  to 
a  child's  head  (figs.  20 
and  21).  Their  position 
and  their  freedom  from 
the  subjacent  bone  dis- 
tinguish them  from  der- 
moids. The  frequently 
observed  family  pre- 
disposition proves  their 
congenital  character. 

Sometimes  these 
cysts  open  spontane- 
ously, leaving  a  sinus 
from  which  fatty  ma- 
terial discharges  itself 
from  time  to  time.  As 
they  usually  become 
infected,  suppuration  also  occurs, 
referred  to  later  on. 


■•IkJ^  ' 


■■0^' 


Fig.  19. — Osteoma  of  frontal  bone. 

Their  malignant  degeneration  is 


^.—ACQUIRED   SWELLINGS   OF   THE    HEAD. 

Sebaceous  cysts  lead  us  to  swellings  of  the  head  and  tumour-like 
formations,  which  develop  in  later  life.  We  have  here  to  distinguish 
between  innocent  and  malignant  structures. 

(i)  Innocent  Acqnired  SivcUings. 

These  are  soon  disposed  of,  because  they  include  only  osteoma 
(fig.  19),  often  of  an  ivory  consistence,  and  soft  fibroma  of  the  skin. 
The  latter  is  usually  but  one  of  several  generalized  fibromata,  and 
therefore  the  diagnosis  can  be  made  at  first  sight. 

Sometimes  a  few  apparently  soft  harmless  warts  may,  after  existing 
for  years,  lead  to  a  fatal  result,  with  the  severe  symptoms  of  Reckling- 
hausen's disease. 


SURGICAL   DISEASES   OF   THE    HEAD 


(2)  Maligiiaut  Tiniwurs  of  the  Head  and  Chronic  Infianiniaiorx 

Swellings. 

(a)  Swellings  which  are  closely  connected  with  the  hone  may  be  of  the 
nature  of  gninnia,  tnbercle,  sarcoma,  or  metastatic  tumour  of  any  kind. 
Gnmmata,  which  never  reach  any  significant  size,  are  generally 
multiple,  and  when  recognizable  as  tumours,  are  usually  soft  in  the 
centre.  They  begin  as  hard  thickenings  of  the  periosteum,  which 
may  be  distinctly  painful  on  pressure,  thus  contrasting  with  the  usual 
painlessness  of  tertiary  syphilitic  lesions.  When  ulcerated,  their 
specific  character  is  attested  by  the  yellowish,  fatty  base  of  the  ulcer, 

by  the  superficial  ne- 
crosis of  the  bone,  by 
the  irregular  ivory-like 
movable  sequestrum, 
and  by  the  new  deposit 
of  bone  round  about. 
If  no  histor}'  of  syphilis 
is  forthcoming,  traces  of 
its  attack  will  probably 
be  found  in  the  form  of 
scars  and  of  irregularities 
on  the  bones.  In  a  doubt- 
ful case  there  will  always 
be  time  to  try  the  effect 
of  potassium  iodide  and 
to  employ  the  Wasser- 
mann  serum  test. 

Tubercle  of  the  skull, 
an  affection  more  fre- 
quent in  children  than 
in  adults,  is  also  often 
multiple  in  character. 
A  focus  of  tubercle  un- 
dergoes softening  much 
earlier  than  a  gumma,  and  as  the  disease  extends,  a  cold  abscess  is 
formed.  These  two  points  are  in  themselves  sufficient  to  distinguish 
the  two  conditions,  especially  as  in  tubercle  there  are  probably  other 
foci  of  disease,  if  only  tubercular  glands.  But  in  no  circumstance 
should  a  non-acute  fluctuating  swelling  of  the  skull  be  incised,  unless 
one  is  prepared  to  proceed  further  forthwith.  If  the  abscess  be  opened 
or  if  it  burst  spontaneously,  the  ulcer  in  the  bone  is  seen  to  have  a 
sharp  edge  as  if  punched  out,  and  if  there  be  a  sequestrum,  it  is 
movable,  easily  liberated,  and  there  is  no  new  bone  formation  round 
about.     These  characters  will  clench  the  diagnosis. 


Fig.  20. — Sebaceous  cyst  on  scalp. 


SWELLINGS    ON   THE    HEAD 


57 


If  we  are  able  to  exclude  both  gumma  and  tubercle,  the  only  condi- 
tion which  remains  is  a  malignant  growth.  As  metastases  in  the  skull 
are  not  rare,  we  should  lirst  search  for  a  primary  focus,  especially  in 
the  thyroid  gland.  It  is  well  known  that  even  an  apparently  innocent 
goitre  may  give  rise  to  secondary  deposits  of  a  malignant  character. 
These  may  occur  anywhere  on  the  skull  and  may  grow  deeply  into 
the  cranial  cavity.  In  contrast  to  certain  sarcomata,  they  are  remark- 
ably soft  to  the  touch.  In  the  absence,  however,  of  any  cause  for  the 
growth,  it  must  be  regarded  as  a  primary  sarcoma,  which  may 
originate  from  the  periosteum,  diploe,  or  dura  mater.  The  starting 
point  can  be  dis- 
tinguished at  lirst         E^-s-T-- —  -X— -^^iF--- — ■  :--    -| 

faiiiy     accurately,  .  ^ 

but  with  the  pro- 
gress of  the  growth 
this  becomes  im- 
possible. 

A  periosteal  sar- 
couia  has  not  any 
superficial  cover- 
ing of  bone,  but 
occasionally  its 
•deeper  parts  are  ; 
ossified.  It  is  not  j 
compressible,  but 
it  pulsates,  if  very 
vascular.  A  sar- 
coma which  starts 
in  the  diploe  is 
covered  superfici- 
ally by  bone,  and 
therefore  resem- 
bles a  simple  ex- 
ostosis. But  soft  areas  soon  appear,  and  it  becomes  more  and  more 
like  a  periosteal  sarcoma.  At  first  it  is  not  compressible  towards  the 
interior  of  the  skull,  and  therefore  is  clearly  distinguishable  from  a 
sarcoma  of  the  dura  mater.  This  latter,  besides  being  compressible, 
is  also  very  pulsatile  and  follows  all  the  oscillations  of  the  brain 
pressure.  Naturally  these  symptoms  will  also  appear  if  a  sarcoma 
of  the  periosteum  or  the  diploe  has  eaten  through  the  bone,  and 
involved  the  dura  mater.  Bergman n  has  described  a  sign  which, 
even  at  this  stage,  may  indicate  the  origin  of  the  growth,  for  in  a 
primary  sarcoma  of  the  dura  the  perforation  in  the  skull  has  a  sharp 
cut  flat  edge,  where    in  a  sarcoma   of  the  diploe,  the  external  table 


Fig.  21. — Giant  sebaceous  cyst. 


58 


SURGICAL    DISEASES    OF   THE    HEAD 


of  the  skull  slopes  towards  the  tumour  like  a  roof.  The  history  will 
also  afford  material  for  a  decision.  If  the  patient  has  been  suffering, 
for  some  time  before  the  growth  became  visible  and  palpable,  fi'om 
persistent  headaches,  and  if  these  have  subsided  with  the  external 
appearance  of  the  grov^'th,  then  it  is  a  primary  sarcoma  of  the  dura 
mater.  If,  on  the  other  hand,  brain  symptoms  only  occur  in  the  later 
course  of  the  disease,  then  we  conclude  that  the  growth  originates 
either  from  the  periosteum  or  bone.  But  if  it  is  obvious  that  the  skull 
cap  has  been  perforated  and  yet  none  of  the  previous  indications  are 
evident,  it  is  useless  to  attempt  any  further  diagnostic  subtleties,  because 
treatment  is  identical  in  either  case. 

(b)   In  cases  of  chronic   ulceration  of  the  skull   the  problems  are 
somewhat  different.     If  the  ulceration  has  attacked  tiie  bone,  and  the 

patient  states  that  it  was 
preceded  by  a  tumour-like 
condition,  we  must  regard 
it  as  gumma  of  the  skull, 
especially  when  the  base  of 
the  ulcer  has  a  5'ellowish, 
fatty  appearance.  With  a 
similar  history,  and  an  ulcer 
freely  miovable  over  the 
bone,  we  should  consider  it 
to  be  an  open  gumma  of  the 
skin.  But  if  we  are  told 
that  the  condition  was  an 
ulcer  from  the  very  begin- 
ning, we  must  think  of  terti- 
ary syphilis  and  epithelioma. 
We  recognize  the  former  bv 
its  shape,  base  and  border, 
apart  from  the  history.  If 
grayish  plugs  can  be  pressed 
out  of  its  border,  and  if  at  the  same  time  the  well-known  predisposing 
changes  are  present  on  the  skin,  viz.,  seborrhcea  and  verruca  senilis, 
there  is  very  little  difficulty  in  arriving  at  the  diagnosis  of  seborrhoeic 
epithelioma.  In  this  instance,  multiplicity  does  not  contraindicate 
the  diagnosis  of  primary  malignant  new  growth.  Finally,  if  the 
patient  states  that  a  sebaceous  cyst,  which  he  has  had  for  many  years, 
has  become  hard,  ulcerated  and  painful — probably  after  an  injury  to 
it — there  can  be  no  doubt  that  the  diagnosis  is  cancerous  degeneration 
of  the  cyst  (see  fig.  22). 


Fig.  22. — Sebaceous  cyst  of  head,  undergone 
cancerous  change. 


ACUTE    IXFLAMMATORY    DISEASES    OF    THE    FACE  59 

CHAPTER    X. 

ACUTE    INFLAMMATORY  DISEASES  OF  THE  FACE. 

All  inflammatorv  processes  about  the  face  rapidly  produce  severe 
swelling,  because  the  skin,  especially  of  the  Hps  and  cheeks,  is  richly 
supplied  with  blood  vessels,  and  the  subcutaneous  tissue  of  the  eyelids 
is  verv  loose.  Wherever  the  origin  of  the  inflammation  may  have 
been,  there  is  a  considerable  resemblance  in  the  appearance  of  all 
these  cases.  The  lips  are  puffed  and  protuberant,  the  cheek  is  bloated, 
the  evelids  are  converted  into  smooth  pads,  between  which  the  eyes 
peep  with  difticultv,  if  thev  are  visible  at  all.  If  we  are  confronted 
with  such  a  case,  an  immediate  diagnosis  cannot  be  made  without  the 
previous  history  and  more  detailed  examination.  The  possibility  of 
erysipelas  will  suggest  itself  first.  This  will  be  confirmed  by  the 
svmmetrv  of  the  swelling,  by  the  deep  redness  of  the  skin  and  the 
shaip  limitation  both  of  the  swelling  and  the  redness.  We  must  not 
look  for  this  limitation  in  the  neighbourhood  of  the  eyelids,  because 
thev  swell  up  at  once  to  their  full  extent,  owing  to  their  anatomical 
characteristics;  the  margin  will  be  on  the  cheek  or  forehead  ;  the 
patient  usually  states  that  the  swelling  began  on  the  nose.  If  he  has 
already  had  previous  attacks,  which  is  verv  likely,  he  will  supplv  the 
diagnosis  himself  and  will  only  want  to  know  whether  any  improved 
method  of  treatment  is  available.  A  careful  examination  of  the 
swelling  will  show  that  it  is  situated  in  the  skin,  and  that  the  deeper 
tissues  are  free.  But  if  erysipelas  is  excluded,  the  diagnosis  usually 
lies  between  one  of  the  following  conditions — Funinde  of  ilie  upper  Up, 
periostitis  of  the  upper  jaw,  acute  iu/taunuatiou  of  the  luaxitlarv  sinus, 
oi"  the  fi'outal  sinus,  iu/iauiuiatiou-  of  the  lachrvuial  sac,  iuflaniiuation 
icitJiiu  the  orbit,  and  linallv,  accidental  infections  of  various  kinds. 

In  regard  to  furuncle  of  the  upper  lip,  which,  at  times,  infects  the 
facial  veins  and  leads  to  pyaemia,  the  original  site  of  infection  must  be 
ascertained  from  the  patient.  It  is  easy  to  overlook  a  furuncle,  which 
is  not  usually  large. 

Acute  periostitis  of  the  upper  jaw,  and  an  acute  exacerbation  of 
inflammation  of  the  maxillary  antrum,  at  first  sight,  appear  to  have 
the  same  symptoms.  Besides  the  swelling,  we  are  struck  in  both  with 
sensitiveness  on  pressure  over  the  canine  fossa  and  the  vestibule  of  the 
mouth,  the  superficial  soft  parts  not  being  affected.  The  difference 
will  usually  be  evident  from  the  history.  In  ordinary  periostitis  there 
will  have  been  previous  toothache,  and  we  shall  probably  find  a  carious 
tooth  or  one  sensitive  to  pressure.  In  a  recent  sinusitis,  a  history  of  a 
preceding  cold  or  influenza  will  often  be  elicited.      If  the  condition  is 


6o  SURGICAL    DISEASES    OF    THE    HEAD 

due  to  an  acute  exacerbation  of  an  old  sinus  inflammation,  careful 
inquiry  will  reveal  the  typical  history  of  all  sinus  catarrhs  with  periods 
when  they  become  much  worse  and  give  rise  to  profuse  discharge  of 
sanious  and  often  foul-smelling  pus.  Objective  examination  will 
frequently  afford  points  of  differentiation.  In  dental  pcrioslitis  the 
swelling  of  the  soft  parts — including  the  gums — is  most  prominent,  and 
the  sensitiveness  to  pressure  of  the  upper  jaw  concerns  mainly  the 
alveolar  process;  but  in  acute  sinusitis  there  is  less  swelling  of  the  soft 
parts.  In  this  condition  the  bone  is  sensitive  to  pressure  as  far  as  the 
infra-orbital  margin,  and  in  addition  there  is  often  a  neuralgia  affecting 
the  cutaneous  branches  of  the  infra-orbital  nerve.  The  nasal  mucous 
membrane  on  the  diseased  side  is  oedematous,  and  nasal  respiration  is 
obstructed.  In  chronic  sinusitis  there  is  generally  hypertrophy  of  the 
mucous  membrane  over  the  middle  turbinated  bone,  and  polypi  are  also 
present.  If  the  patient  does  not  happen  to  be  suffering  from  retention 
of  the  discharge  at  the  time  of  the  examinations,  we  may  be  able  to 
detect  pus  escaping  from  beneath  the  middle  turbinated  bone  if  the 
examinations  are  repeated  often  enough.  Finally,  diagnosis  may  be 
facilitated  by  puncturing  the  sinus  from  below  the  nasal  duct. 

If  the  inner  angle  of  the  eye,  which  is  generally  swollen  up 
and  very  painful,  is  the  centre  of  the  inflammatory  disturbance, 
the  condition  originates  from  the  lachrymal  sac,  and  a  phlegmonous 
Dacrocystitis  exists.  The  tears  run  over  the  lid,  showing  that  the 
lachrymal  canal  is  blocked,  and  the  patients,  who  usually  have  had 
previous  attacks  and  are  well  posted  in  the  details  of  their  cases,  will 
often  relate  their  experiences  of  probing  the  tear  duct. 

These  inflammatory  processes  have  frequently  been  traced  to  a 
streptothrix  infection. 

Inflammation  starting  from  the  frontal  sinus  is  recognized  by  the 
forehead  and  upper  lid  being  chiefly  involved.  Its  previous  history 
resembles  that  of  inflammation  of  the  maxillary  sinus. 

Mild  cases  of  frontal  sinusitis  are  often  mistaken  for  supra-orbital 
neuralgia.  It  is  quite  true  that  secondary  inflammation  of  the  nerve 
may  occur,  but  it  is  important  to  recognize  the  original  and  causative 
factor.  Pressure  on  the  wall  of  the  sinus  near  the  nerve  generally 
suffices  for  this. 

As  we  are  dealing  with  the  bony  margin  of  the  orbit,  we  may 
refer  to  a  not  uncommon  disease  in  children,  which  sometimes 
presents  itself  as  an  acute  inflammation — i.e.,  tubercle  of  the  superior 
maxilla,  affecting  the  lower  margin  of  the  orbit.  This  leads  to  sinus 
formation,  and  as  there  is  invariably  some  secondary  infection, 
extensive  swelling  of  the  soft  parts  occurs  if  secretion  is  retained. 
Tubercle  of  the  lachyrmal  sac  should  be  mentioned  here,  a  typical 
illustration  of  which  is  seen  in  fig.  23. 

Inflammatory  diseases  of  the  orbital  contents  present  a  uniformly 
similar  picture,  because  the  swelling  is  more  or  less  sharply  circum- 


ACUTE    INFLAMMATORY    DISEASES    OF   THE    FACE 


6i 


scribed  by  the  conjunctiva  and  the  Hds,  and  because  the  globe  of 
the  eye  is  usually  protruded.  The  only  exception  to  this  last  symptom 
is  in  inflammation  of  the  lachrymal  glands,  which  is  recognized  by 
the  situation  of  the  swelling,  chiefly  on  the  outer  side  of  the  upper 
lid  and  the  adjoining  part  of  the  forehead.  If  the  globe  is  protruded 
and  both  lids  are  puffed  like  pillows,  the  diagnosis  can  only  be 
between  a  retrobulbar  abscess  and  a  venous  thrombosis  in  the 
retrobulbar  fatty  tissue,  or  in  the  cavernous  sinus.  It  is  not  easy 
to  distinguish  between  these  two  processes,  because  both  the 
symptoms  and  the  etiology  are  alike,  the  cause  generally  being  some 
focus  of  inflammation  on  the  face  or  the  bony  structure.  Facial 
erysipelas,  furuncle  of  the  face,  ostitis  and  periostitis  of  the  upper 
jaw  are  mainly  responsible  for  these  conditions. 

If  the  symptoms  are  on  both  sides,  they  must  be  due  to  ilironihosis 

of  both  sinus  cavernosi.  Surgical  interven- 
tion has,  unfortunately,  failed  hitherto  in 
these  cases. 

A  little  boy  who  was  suffering  from  a 
persistent  suppurative  periostitis  of  the 
jaw  had  a  lower  molar  extracted  bv  a 
quack — the  same  thing  may  have  hap- 
pened if  the  operator  had  been  a  dentist 
or  a  doctor.  Immediately  afterwards,  the 
lids  of  both  eyes  began  to  swell,  the  globes 
protruded,  rigors  occurred,  and  the  tem- 
perature rose  to  102° — 104°  F.,  the  pulse 
failed,  consciousness  was  lost,  and  death 
ensued  a  few  days  after  the  onset  of  the 
symptoms,  as  is  usual  with  septic  throm- 
bosis of  the  sinus  cavernosi. 

If  the  disease  is  miilaieral  we  must  seek 
to  differentiate  as  quickly  as  possible  be- 
tween thrombosis  and  abscess,  in  order  to 
institute  appropriate  treatment.  As  long  as  both  lids  are  equally  swollen 
without  any  circumscribed  redness,  and  in  the  absence  of  severe 
pyrexia,  we  may  regard  the  condition  as  retro-orbital  thrombosis  with- 
out purulent  softening,  and  we  are  justified  in  waiting.  But  if  one  lid, 
especially  the  upper,  swells  up  more  and  becomes  redder  and  painful, 
it  means  that  there  is  pus  deeply  situated  and  we  must  interfere. 

The  following  case  is  very  instructive  in  this  connection.  A 
patient  who  had  been  bitten  by  a  friend  in  the  left  upper  lid,  was 
brought  into  the  hospital  suffering  from  erysipelas.  The  disease 
spread  over  the  entire  head,  and  caused  several  subcutaneous 
abscesses.  After  these  had  healed,  swelling  of  the  lids  suddenly  started 
again  on  the  side  which  had  been  bitten,  and  exophthalmos  followed. 
The  swelling  was  equally  distributed  over  both  lids,  but  there  was 


J 


Fig.  23. — Tuberculosis  of  the  lach- 
rymal sac. 


62  SURGICAL    DISEASES    OF    THE    HEAD 

no  very  striking  puffiness  at  any  one  place.  The  temperature 
remained  normal.  The  history  suggested  an  abscess,  but  the 
regularity  of  the  swelling  and  the  absence  of  fever  nevertheless  made 
it  probable  that  the  condition  was  thrombosis.  We  awaited  develop- 
ments, ready  for  immediate  operation.  In  a  few  days  symptoms  began 
to  subside,  and  finally  vanished  completely  without  any  complication. 
The  diagnosis  of  thrombosis  was  evidently  correct,  and  an  untimely 
operation  would  only  have  done  damage. 

Acute  parotitis  remains  to  be  mentioned  among  the  acute 
inflammatory  swellings  of  the  face.  The  malady  is  immediately 
recognized  by  the  situation  of  the  swelling  in  front  of  the  ear  and  by 
its  extension  to  the  tissues  behind  the  ear  lobule.  If  the  temperature 
is  high  and  both  sides  are  quickly  involved,  the  diagnosis  is  epidemic 
parotitis,  recognized  by  the  stupid  frog-like  expression  which  the 
features  acquire  when  the  disease  is  aggravated  in  this  manner. 
Orchitis,  which  is  a  frequent  complication  in  some  epidemics,  affords 
an  unwelcome  confirmation  of  the  diagnosis.  The  unilateral  parotitis 
which  follows  infectious  diseases — typhoid  fever,  erysipelas,  appendi- 
citis, (&c. — is  quite  different  in  character,  and  usually  breaks  down 
into  an  abscess.  Finally,  there  is  the  acute  swelling  of  the  parotid 
gland  due  to  obstruction  of  Steno's  duct,  by  salivary  calcuVu 
This  condition  is  characterized  by  the  frequency  of  relapses. 


CHAPTER  XI. 

TUMOURS  AND  ULCERS  OF  THE  FACE. 

The  first  matter  to  determine  in  regard  to  any  swelling  of  the  face 
is  whether  it  originates  in  the  skin  or  the  deeper  tissues.  If  the  skin 
is  movable  over  the  growth,  the  latter  has  a  deep  origin  ;  but  if  it  is 
not  possible  to  pick  up  the  skin  free  from  the  growth,  it  is  obviously 
situated  within  the  skin,  as  long  as  the  growth  and  the  skin  are  together 
movable  over  the  subjacent  tissue.  If  the  skin,  tumour,  and  under- 
lying tissue  are  welded  together  into  one  immovable  mass,  it  means 
that  either  the  tumour  has  penetrated  into  the  skin  from  the  deeper 
tissues,  or  has  invaded  these  tissues  from  the  skin.  Experience  shows 
that  the  former  contingency  is  the  more  frequent. 

.4.— TUMOURS    WITH    OVERLYING    SKIX    UNBROKEN. 

We  limit  ourselves  to  tmiiours  of  the  skin,  because  we  have  already 
considered  new  growths  arising  from  deeper  structures,  when  discussing 


TU.MOUKS    AND    ULCERS    OF   THE    FACE 


63 


diseases  of  the  skull  and  jaw.  Dermoids  and  sebaceous  cysts 
need  not  detain  us  long.  Every  beginner  recognizes  that  a  semi- 
globular  tumour  of  the  skin  is  a  sebaceous  cyst,  and  he  is  usually 
correct,  if  the  growth  is  really  situated  ///  the  skin.  But  if  the  skin 
can  be  picked  up  distinctly  free  from  the  tumour,  then  the  latter  is 
more  deeply  placed,  and  is  not  a  sebaceous  cyst,  but  a  subcutaneous 
dermoid.  The  superior  orbital  margin  is  its  favourite  site.  It  is 
nnportant  to  differentiate  between  these  two,  because  a  dermoid  is 
not  so  easih^  shelled  out  as  a  sebaceous  cyst.     A  dermoid  is  frequently 


Fig.  24. — Supra-orbital  dermoid. 


Fig.  25. — Supra-orbital  dermoid. 


seated  in  a  depression  of  bone,  and  requires  detaching  therefrom 
(figs.  24  and  25). 

It  is  hardly  necessary  to  warn  against  confusing  a  hernia  of  the 
brain,  either  with  a  dermoid  or  a  sebaceous  cyst.  Fig.  26  indicates 
how  easily  such  a  mistake  might  be  made,  the  sebaceous  cyst  occupying 
the  position  of  a  frontal  cephalocele. 

Sebaceous  cvsts  are  especially  prevalent  on  the  cheeks  and  the 
temples,  but  lipomata  also  occur  there,  and  the  differential  diagnosis 
is  not  always  easy. 

We  need  not  devote  much  time  to  angiomata  of  the  various  kinds 
(see  fig.  28).     Their  shape  and  colour  proclaim  their  diagnosis,  and 


64 


SURGICAL   DISEASES   OF   THE    HEAD 


any  doubt  is  dispelled  by  the  fact  that  they  can  be  dispersed  by  pressure. 
A  pulsating  mass,  like  earthworms  in  outline,  will  be  identified,  by  a 
beginner  even,  as  a  cirsoid  aiieiirysni. 

Xanthelasma,  a  flat,  pale,  yellow  growth,  often  situated  symmetri- 
cally in  the  n.eighbourliood  of  the  lids,  is  at  once  recognizable  by  its 
colour. 

A  calcified  epitheliouia,  so-called,  may  be  referred  to  here  as  a 
rarity.  It  appears  as  a  round,  flattened,  and  somewhat  nodular 
tumour,  which  can  be  shelled  out  of  the  skin  quite  easily,  and  is 
chalky  on  section.  If  once  seen,  it  is  always  recognizable,  but  the 
inexperienced  cannot  be  expected  to  be  able  to  make  the  diagnosis. 

The  cartilaginous  pendu- 
I —  lous  tumours  of  the  skin,  in 

'  front  of  the  ear,  and  the  soft 
cutaneous  warts  so  frequent 
on  the  face  of  an  old  syphilitic 
subject,  are  too  obvious  to 
detain  us.  But  these  soft 
cutaneous  warts  acquire  some- 
thing more  than  cosmetic  im- 
portance when  they  become 
malignant.  Rapid  growth,  an 
increasing  firmness  in  con- 
sistence, and  bleeding  when 
lightly  touched,  are  clear 
proofs  of  this  change. 

Angioma  and  Lymph- 
angioma of  the  ear  are  not 
very  common,  but  they  are 
easily  recognizable.  Lupus  in 
this  situation  often  resembles 
a  tumour  (fig.  41),  and  haema- 
toma  of  the  ear,  which  occurs 
in  the  insane,  is  also  strikingly 
similar  to  a  tumour  (fig.  27.) 


Fig.  26.  — Sebaceous  cyst  at  root  of  nose. 


5.— ULCERATIVE   PROCESSES. 

Diagnostic  interest  attaches  to  lesions  of  the  skin  of  the  face, 
which  are  ulcerated  from  the  beginning,  or  have  broken  down  after  a 
brief  duration. 

(i)  We  shall  adopt  a  topographical  order,  starting  with  the  lips. 
A  deep  chronic  ulcer  of  the  lip  is  either  a  primary  sore  or  a  cancer. 
The  hardness  of  the  base  constitutes  no  distinction,  because  this  charac- 
ter belongs  to   them  both.     Their  appearance  is  of  more  conclusive 


TUMOURS   AND   ULCERS   OF   THE    FACE 


65 


import.  If  we  can  squeeze  out  small  whitish  plugs,  consisting  micro- 
scopically of  squamous  epithelium,  the  case  is  one  of  cancer.  If  the 
base  consists  of  a  uniformly  reddish,  varnished-looking  tissue,  w^hich 
yields  no  plugs,  it  is  probably  a  primary  sore.  The  condition  of 
the  lymphatic  glands  is  unimportant.  Although  the  presence  of  hard 
enlarged  glands  is  looked  upon  as  confirmatory  of  the  diagnosis  of 
cancer,  their  very  absence  in  this  case  may  lead  us  to  the  same 
diagnosis.  For  a  primary  sore  which  has  existed  for  a  few  weeks  is 
invariably  accompanied  by  enlarged  glands,  whereas  they  may  not 
appear  in  cancer  of  the  lip  for  many  months. 

We  see,  therefore,  that  the  diagnosis  of  cancer  of  the  lip,  in  the 
ulcerative  stage,  is  easy.  It  is  quite  different,  however,  in  the  early 
stage,  when  the  disease  is  either  overlooked  or  neglected  by  the 
patient — a  circumstance  pardon- 
able in  the  patient,  but  unpardon- 
able in  the  medical  attendant.  If 
a  person  complains  of  a  some- 
what hard  sore  place,  covered  by 
a  crust,  on  his  lower  lip,  which 
bleeds  on  removal  of  the  crust, 
we  must  not  follow  the  ancient 
practice  of  touching  the  spot  with 
caustic,  instead  of  making  a  dia- 
gnosis. A  spot  which  has  been 
forming  crusts  for  months,  and 
which  bleeds  slightly,  is  not  some- 
thing which  "  may  become  malig- 
nant," as  is  often  said  as  a  matter 
of  precaution,  but  is  actually  car- 
cinoma, and  must  be  radicallv 
removed  without   regard    to    the 

subsequent  appearance  of  the  lip,  beard,  or  moustache.  We  usually 
see  carcinoma  of  lip  affecting  the  lower  lip  in  males  only  (fig.  29), 
but  occasionally  the  upper  lip  is  attacked  (fig.  30),  and  also  the  female 
sex,  whether  or  not  the  habit  of  smoking  a  pipe  has  been  indulged 
in. 

(2)  The  nose  is  another  favourite  situation  for  ulcers.  If  the  ulcer 
is  in  the  vicinity  of  the  nostrils,  lupus  and  tertiary  syphilis  must  be 
thought  of  first.  The  clinical  history  is  extremely  important  in  these 
cases,  not  only  from  a  general  aspect,  but  also  in  regard  to  the 
evolution  of  the  nasal  disease.  Much  diagnostic  labour  will  be  saved 
by  exhaustive  cross-examination  of  patients,  and  by  examinations  of 
the  brothers,  sisters,  and  children,  in  doubtful  cases. 

The  course  of   the   disease  is  of   special    significance  in    chronic 


Fig.  27. — Haematoma  of  the  ear.     (From 
the  Ear  Clinic,  Basle.) 


66 


SURGICAL    DISEASES    OF    THE    HEAD 


inflammatory  ulcerative  aftections  of  the  nose.  It  enables  us  some- 
times to  make  an  immediate  diagnosis,  when  objective  examination 
leaves  us  in  doubt.  It  may  be  postulated  as  a  general  rule  that  the 
various  tuberculides  of  the  skin,  grouped  together  under  the  name  of 
lupus,  persist  for  months  and  even  years,  whereas  the  duration  of 
tertiarv  svpJi Hides  is  merely  weeks,  or  at  most  a  few  months. 

In  cases  of  lupus  we  may  learn  of  occasional  improvement,  but 
never  of  spontaneous  and  complete  cure.  In  cases  of  tertiary  syphilis 
the  patients  will  often — not  always— tell  of  some  exacerbations,  with 
intervals  of  complete  cure,  marked,  of  course,  by  scar  formation.  If 
the  patient    is  suffeiing  from   a  first    attack,  the    duration   will   have 

been  much  less  than  in  a 
case  of  lupus,  with  a  lesion 
of  the  same  extent. 

Let  us  now  investigate 
the  nose  and  its  vicinity 
a  little  more  closely.  If, 
despite  a  long  duration,  the 
whole  process  is  not  accom- 
panied by  ulceration,  we 
should  at  once  think  of 
tubercle.  But,  on  the  other 
hand,  the  presence  of  ulcera- 
tion is  not  conclusive,  be- 
cause both  lupus  and  gumma 
can  ulcerate.  If  the  ulcer  is 
serpiginous  in  outline,  and 
has  sharply  defined  edges 
with  a  fatty  base,  we  must 
regard  it  as  syphilitic.  If, 
however,  we  find  slightly 
bleeding  ulcerated  areas 
situated  beneath  scabs,  with 
some  grey  nodules  suggestive 
of  tubercle  on  these  areas,  then  the  diagnosis  is  lupus.  The  recognition 
of  these  points,  however,  requires  much  practice.  It  is  easier  to  draw 
conclusions  from  the  area  surrouudiug  the  infiltrated  or  ulcerated  site, 
and,  therefore,  this  requires  very  careful  examination.  If  the  change 
consists  of  separate  very  red  nodules,  nearer  to  peas  than  to  lentils  in 
size,  which  suppurate  in  the  centre,  or  rather,  become  necrotic,  running 
together  into  an  irregularly  circular  ulcer,  the  case  is  syphilitic.  But 
if  we  observe  in  the  vicinity  of  a  superficially  eroded,  brownish-red, 
soft,  infiltrated  area,  separate  little  nodules  hardly  as  big  as  lentils, 
situated  under  a  normal  or  very  scaly  epidermis,  and  which  change 


Fig.  28. — Angioma  of  the  forehead. 


TUMOURS   AND   ULCERS    OF   THE    FACE 


67 


when  pressed  upon  by  a  glass  side,  into  little  light  brown  spots,  the 
nodules  are  certainly  those  of  hipus.  Their  softness  is  very  significant ; 
a  line  probe  can  easily  be  thrust  within  them  from  the  epidermis  with- 
out any  violence.  The  hypertrophic  forms  of  lupus  must  not  be  over- 
looked. These  are  characterized,  besides  the  small  nodules  just 
described,  by  larger,  soft,  non-ulcerated  nodules,  or  by  thick,  light, 
brownish-red  plaques  of  soft  tissue,  several  centimetres  in  extent. 

These  indications  will  suffice  for  the  local  conditions,  and  they  are 
usually  quite  adequate  for  the  purposes  of  diagnosis,  having  due  regard 
to  the  clinical  history. 

We  have  not  yet  men- 
tioned cancer.  This 
disease  does  not  gener- 
ally attack  the  region  of 
the  nostrils,  like  lupus 
and  syphilis,  but  rather 
the  bridge  of  the  nose, 
its  lateral  walls  (figs.  31 
and  32),  and  the  naso- 
labial fold.  The  hard- 
ness of  its  margin  and 
base  distinguishes  it  im- 
mediately from  lupus 
and  syphilis,  even  in 
the  chronic  flat  varieties. 

As  far  as  its  duration 
is  concerned,  it  may  be 
said  that  an  ulcer  which 
has  persisted  for  weeks, 
or  for  a  few  months,  and 
which  is  constantly  in- 
creasing in  size,  is  always 
suspicious  of  cancer. 
But  on  the  other  hand, 
the   fact    that    an    ulcer 

has  persisted  for  years,  and  has  evinced  signs  of  partial  healing,  or 
rather  epithelization,  is  not  always  a  conclusive  argument  against 
cancer.  Indeed,  we  shall  soon  see  that  this  course  is  significant  of 
a  definite  variety  of  cancer.  Although  lupus  frequently  runs  a  similar 
course,  the  signs  already  given,  and  others  which  will  be  referred  to 
subsequently,  will,  as  a  rule,  prevent  any  confusion.  The  superficial 
cancer,  known  as  rodent  nicer,  often  has  a  few  little  nodules  on  its 
smooth  scars,  just  like  lupus.  But  in  contrast  to  the  latter,  they  are 
whitish,  hard,  cannot  be  penetrated  by  the  probe,  and  they  do  not 


Fig.  29. — Cancer  of  lower  lip. 


68 


SURGICAL    DISEASES    OF   THE    HEAD 


leave  the  brownish  stains  on  pressure  with  a  glass  slide.  These  little 
nodules  appear  to  be  isolated,  but  they  are  really  arranged  in  a  circular 
manner,  and  are  mainly  to  be  found  at  the  edge  of  the  cicatrized 
surface  (fig.  32). 

Although  many  of  these  cancers  are  very  benign,  it  is  important 
to  diagnose  them  before  destruction  of  the  deeper  tissues  occurs,  and 
their  early  stages  must  be  well  recognized. 

If  we  are  consulted  about  a  somewhat  hard  patch,  scarcely  raised 
above  the  surrounding  part — a  patch  which  is  constantly  scaling  over, 
or  is  covered  in  the  centre  by  a  small  crust,  under  which  a  slightly 

bleeding  surface  is  evi- 
dent, we  can  be  con- 
fident that  we  are  deal- 
ing with  the  form  of 
!  skin  cancer,  designated 

^~  as    rodent    ulcer    (figs. 

32  to  34).  It  is  a  condi- 
tion which  will  gradu- 
ally begin  to  invade 
the  subjacent  tissue, 
after  lasting  for  years. 
Its  oldest  parts  are 
characterized  by  central 
smooth  scarring  ;  its 
margin  is  of  cartilagi- 
nous consistence,  thick 
and  whitish.  There  is 
always  some  con- 
traction round  about, 
causing  the  lips  to  be 
drawn  up,  the  eyelids 
to  be  pulled  down,  or 
the  cheeks  to  be  drawn 
in,  &c.,  according  to 
the  site  of  the  new 
The  glands  are  rarely  enlarged.  If  the  disease  has  invaded  the 
deeper  structures,  the  skin  becomes  adherent  to  the  underlying  bone. 
Once  this  stage  has  developed  the  destruction  continues  slowdy,  but 
inevitably,  involving  the  eyelids,  invading  the  eyeball,  eating  into 
the  nose  and  exposing  its  accessory  sinuses,  but  nowhere  causing  any 
definite  tumour  formation. 

Sometimes  we  are  confronted  with  a  semi-globular  wart-like 
structure,  which  scales  in  the  centre  (fig.  35).  Even  in  this  condition, 
the  diagnosis  is  quite  easy.  It  is  differentiated  from  a  fibroma  of  skin, 
which  is  so  frequent  on  the  face,  by  its  dense  consistence  and  brief 


L*. 


Fig.  30. 


-Cancer  of  upper  lip. 


growth 


TUMOURS   AXD    ULCERS   OF   THE    FACE 


69 


Fig.  31. — Tumcur-like  cancer  of  nose.  FlG.  32.  --Cicatrizing  flat  cancer.    (Rodent  ulcer.) 


I^iG.  33.  —Cutaneous  cancer  of 
angle  of  eye.     (Rodent  ulcer.) 


Fig.  34. — Rodent  ulcer  of  cheek 
in  early  stage. 


70  SURGICAL   DISEASES    OF   THE    HEAD 

life-history.  The  absence  of  anv  inflammation  and  its  sharplv  definite 
limits  show  that  it  is  not  of  the  nature  of  acne,  while  the  scaling 
indicates  some  hvperactivity  of  the  epithelium,  if  the  wart  has  broken 
down  into  an  ulcer  with  tumid  proliferating  edges  (fig.  36),  or  if  it  has 
become  a  fungating  or  hornv  structure  projecting  from  the  skin 
(fig.  31)  the  diagnosis  will  be  obvious,  even  to  the  inexperienced. 
The  progress  of  this  form  of  cancer  is  quite  different  from  that  of 
rodent  ulcer,  because  the  destruction  wrought  bv  it  in  the  course  of 
months,  requires  years  in  the  case  of  the  rodent  ulcer.  Further,  the 
destruction  is  accompanied  bv  much  tumour  formation,  whereas  this 
is  not  characteristic  of  rodent  ulcer. 


Fig. 


—Wart-like  cancroid 
of  nose. 


Fig.    30.  —  Cancrfiid  oi  tijH  with 
wall  like  margin. 


Several  authors  have  latelv  separated  cutaneous  cancers  from 
epithelial  new  growths,  and  classified  them  with  cndotlicUoinata.  But 
as  this  view  has  been  contested  from  the  histological  standpoint,  and 
as  no  clinical  differences  have  hitherto  been  demonstrated,  we  may 
safely  adhere  to  the  older  conception. 

(3)  We  now  come  to  ulcers,  or  structures  which  ulcerate  earlv, 
in  the  neighbourhood  of  the  lids. 

A  roundish  little  growth,  varving  in  size  from  a  hempseed  to  a 
pea,  and  somewhat  drawn  in  at  the  top,  must  be  looked  on  as  very 
suspicious  of  cancer.  It  is  distinguished  from  molluscum  con- 
tagiosum,  because  the  latter  is  softer  and  is  rarely  single,  others 
being  usually  found  close  bv,  or  towards  the  neck.  If  the  contents 
are  expressed,  thev  will  be  seen  to  resemble  the  interior  of  a  sebaceous 
cvst,  and  under  the  microscope,  will  show  the  well-known  homo- 
geneous  molluscum  bodies.     If  we  squeeze  an   incipient  cancer,  we 


TUMOURS    AND    ULCEKS    OF   THE    FACE 


7.1 


we  may  obtain  a  few 
epithelial  plugs,  but  we 
cannot  empty  the  little 
tumour  as  we  can  a 
moUuscum. 

(4)  The  remarks 
concerning  growths  of 
the  nose  and  eyelids 
apply  equally  to  the 
neighbourhood  ofthe 
cheeks.  Lupus  is  the 
most    frequent    lesion 

(figs-  37,  38>  39)  ^"id 
then  comes  cancer, 
mostly  in  the  form  of 
rodent  ulcer  (tig.  34). 
If  all  the  facts  are  not 
consistent  with  a  dia- 
gnosis of  cancer,  one 
must  also  think  of 
molluscum  contagi- 
osum,  just  mentioned. 
In  this  connection  the 
so-called  telangiectatic 
granuloma  should  be  re- 
ferred to. 

(5)  Ulcers  frequently  form 
on  the  forehead  and  temple 
at  the  margin  of  the  hair. 
These  are  usually  sebor- 
rhoeic  cancers  of  the  skin. 
They  occur,  as  a  rule,  in  old 
syphilitics,  whose  skins  show 
very  definite  signs  of  se- 
borrhoea  and  present  other 
changes  predisposing  to 
cancerous  induration,  such 
as  senile  warts  and  even 
cutaneous  horns.  Such  can- 
cers may  be  multiple. 

In  young  persons  an  ulcer 
at  the' margin  of  the  hair  is 
very  suggestive  of  an  ulcer- 
ated syphilide. 


Fig.  37.  —  Lupus  of  the  face. 


!l^ 


Fig.  38. — Lupus  of  the  face. 


72 


SURGICAL   DISEASES    OF   THE    HEAD 


(6)  Ulcers  of  the  auricle  are  generally  cancroids.      If  left  alone, 
they  lead  to  complete  destruction  of  the  auricle. 

Lupus  in  this  position  is  more 
rare.  In  its  hypertrophic,  non- 
ulcerating  form,  it  looks  very  much 
like  a  tumour  (fig.  41.) 

Ulcers  which  have  persisted  for 
some  time,  not  situated  on  the 
typical  positions  already  referred 
to,  may  be  suspected  of  another 
origin.  For  instance,  if  a  patient, 
who  is  accustomed  to  patronize  a 
barber,  has  recently  acquired  an 
ulcer  on  the  chin  or  cheek,  a 
primary  chancre  must  be  thought 
of,  at  any  rate,  so  long  as  the  asepsis 
of  the  barber  has  not  reached  the 
desired  standard. 

A  primary  chancre  on  the  con- 
junctiva may  lead  to  mistakes.  A 
workman  allowed  his  companion 
to  remove  a  foreign  body  from  his 
conjunctiva.  A  little  piece  of  wood 
had  been  used  for  this  purpose,  which,  according  to  a  very  dniy 
custom    (to  put  it  mildly)  had    been    previously    sucked    by    several 


Fig.  39. — Lupus  of  the  nose. 


Fig.  40. — Cancroid  of  the  ear. 


Fig.  41. — Tuberculosis  of  lobe  of  ear 

(Lupus  hypertrophicus). 

(From  the  Ear  Clinic,  Basle.) 


people.     The  foreign  body  was  successfully  removed,  but  at  the  same 
tiziie  the  spirochaete  was  inoculated. 


INJURIES    OF   THE   JAW  73 

CHAPTER    XII. 
INJURIES  OF  THE  JAW. 

Fractures  of  the  lower  jaw  are  so  easily  recognized  that  they 
hardly  require  any  discussion.  The  most  important  question  to  ask 
is,  whether  the  jaw  has  been  completely  fractured  transversely,  or 
whether  merely  the  alveolar  process  has  been  broken  off.  The 
severe  disturbance  of  function,  the  position  of  the  teeth,  and  lateral 
pressure  and  counter-pressure  in  the  neighbourhood  of  both  angles  of 
the  jaw,  will  answer  this  question  without  any  difficulty. 

A  complete  fracture  may  be  overlooked  when  it  is  situated  near  the 
angle  of  the  jaw  or  on  the  ascending  ramus,  that  is  to  say,  when  it  is 
outside  the  region  of  the  teeth.  But  careful  examination  ought,  as 
a  rule,  to  detect  it,  because  the  loss  of  function  and  pain  on  local 
pressure  are  both  very  definite,  even  when  there  is  no  crepitus.  The 
following  case,  however,  gives  an  example  to  the  contrary  : — 

A  dentist,  in  extracting  a  wisdom  tooth,  imconsciously  broke  the 
jaw,  which,  in  that  situation,  was  somewhat  atrophic.  No  conclusion 
could  be  drawn  from  the  position  of  the  teeth,  because  the  fracture 
was  at  the  angle  of  the  jaw,  and  because  there  was  no  displacement. 
The  patient  only  complained  of  severe  neuralgia  in  the  mandibular 
nerve,  and  this  diverted  attention  from  the  injury  to  the  bone,  no 
suspiciori  being  entertained  that  the  neive  might  be  nipped  between 
the  two  fragments.  It  was  not  until  a  phlegmon  started  at  the  seat 
of   fracture  that  attention    was    directed    to  the  accident. 

Fractures  of  the  upper  jaw  more  frequently  escape  recognition. 
Not,  of  course,  fractures  of  the  alveolar  process  due  to  violent  extrac- 
tion of  teeth,  or  when  the  jaw  is  shattered  by  such  an  injury  as  a 
revolver  shot  for  suicidal  purposes.  When  all  the  bones  of  the  face 
are  torn  asunder,  the  diagnosis  of  a  fractured  upper  jaw  presents 
neither  difBculty  nor  interest.  But  on  the  other  hand,  it  is  important 
to  recognize  a  fissured  fracture  when  the  soft  parts  are  uninjured  and  the 
seat  of  fracture  not  exposed.  This  may  occur  when  a  force  is  applied 
flat  to  the  face,  both  upper  and  lower  jaw  being  fractured  transversely. 
The  most  striking  symptom  which  comes  on  after  the  blow  is 
bleeding  from  the  mouth  and  nose  ;  but  this  is  not  significant  of 
fracture,  because  this  may  follow  a  simple  wound  of  the  nose.  The 
presence  of  a  rent  in  the  mucous  membrane,  or  at  least  a  submucous 
haemorrhage  of  the  alveolar  process  of  the  palate,  is  more  important. 
Preternatural  mobility,  or  displacement  of  one  of  the  fragments,  would 
be  conclusive  evidence.  But  this  is  likely  to  be  missed  in  a  superficial 
examination,  because  the  displacement  is  much  less  than  in  the  case 
of  the  lower  jaw.     If,  however,  the  patient  complains  that  some  of  his 


74 


SURGICAL    DISEASES    OE   THE    HEAD 


teeth  have  "become  too  long"  we  may  assume  tliat  we  have  over- 
looked some  abnormality  in  position,  and  that  a  fracture  is  present. 
This  very  signiticant  statement  permits  of  the  diagnosis  being  made 
long  after  the  accident.  Pain  is  also  an  important  sign.  It  is  easy 
to  demonstrate  bv  external  pressure  that  there  is  pain  on  the  anterior 
surface  of  tb.e  upper  jaw,  unless  a  haemorrhage  on  the  cheek  prevents 
palpation.  If  such  pain  is  limited  to  a  definite  position,  we  have 
every  right  to  suppose  that  there  is  a  fracture.  Sometimes  the  pain 
can  be  traced  straight  across  to  the  opposite  jaw.  This  supposition 
will   be    confirmed  if  pressure  on  the  teeth  either  in  an  upward  or 

lateral  direction  elicits  definite 
pain,  whether  accompanied 
by  crepitus  or  not.  If  sen- 
sation is  disturbed  in  the 
region  of  the  infra-orbital 
nerve,  especially  if  sensi- 
bility is  diminished  and 
neuralgia  exists,  this  affords 
further  confirmation  of  the 
diagnosis. 

The  recognition  of  such 
fractures  of  the  upper  jaw, 
or  even  of  less  marked  ones, 
has  something  more  than 
a  mere  diagnostic  interest, 
because  the  line  of  fracture 
may  continue  onwards  to 
the  base  of  the  skull  and 
involve  other  nerves,  par- 
ticularly the  optic  nerve. 
Such  fractures  may  even 
lead  to  meningitis. 
_  A  woman  was  struck  on 

the  cheek  by  a  drunken 
peasant.  A  few  weeks  later 
there  still  remained  pain  on 
pressure  over  the  canine  fossa,  the  feeling  of  long  teeth,  and  a 
trigeminal  neuralgia.  Careful  examination  showed  that  the  affected 
eye  was  blind,  and  the  ophthalmoscope  revealed  optic  atrophy, 
proving  that  the  fracture  had  reached  the  area  of  the  optic  nerve. 
Partsch  has  even  seen  a  case  of  bilateral  blindness  from  this  cause. 
Dislocation  of  the  lower  jaw  need  not  detain  us.  The  patient 
with  his  lower  jaw  pushed  forward,  with  his  mouth  open,  unable  to 
open  it  any  wider  or  close  it,  presents  such  a  characteristic  aspect  that 
even  the  layman  can  diagnose  it  forthwith  (fig.  42).      ' 


Fig.  42. — Dislocation  of  lower  jaw. 
(From  the  surgical  clinic  at  Berne.) 


LOCK-JAW  75 

CHAPTER    XIII. 
LOCK-JAW. 

Whereas  the  inability  to  sJuit  the  mouth  invariably  points  to 
dislocation,  inability  to  open  it  "may  be  due  to  various  causes. 

Let  us  begin  with  a  rare  case  : — - 

A  young  girl  was  attacked  suddenly,  from  time  to  time,  with 
inexplicable  seizures  of  lock-jaw,  which  disappeared  when  the  patient 
was  semi-anjesthetized.  This  was  evidently  a  functional  condition,  a 
spasm,  which  Kocher  compares  to  spastic  torticollis,  and  which  we 
must  assign  to  the  wide  domain  of  neuroses. 

The  rare  cases  of  trismus,  due  to  an  apoplectic  lesion  in  the  lower 
frontal  convolution,  must  also  be  classified  as  lockjaw  of  nerve 
origin.  The  lockjaw,  due  to  tumours  of  the  pons,  is  a  peripheral 
irritative  symptom. 

The  following  kind  of  case  is  much  more  frequent:  The  patient 
had  taken  a  three  hours'  walk  from  the  country  into  town  to  consult 
a  doctor,  because  he  had  been  unable  to  open  his  mouth  for  the  last 
fortnight,  owing  to  "a  bad  tooth."  Besides  his  lockjaw,  he  had  facial 
paralysis  of  the  left  side,  and  a  small  unirritating  scar  over  his  left 
eyebrow.  The  latter  was  due  to  an  injury  from  an  axe,  sustained 
four  weeks  previously.  All  the  reflexes  were  increased,  the  gait  was 
somewhat  stiff,  and  there  was  a  grinning  facial  expression  on  the 
unparalysed  side  (fig.  43). 

This  really  constitutes  the  classical  picture  of  head  tetanus.  The 
beginner,  who  thinks  of  the  victim  of  tetanus  as  absolutely  in- 
capacitated, would  probably  be  misled  by  the  history  of  the  three 
hours'  walk.  But  patients  with  tetanus  often  come,  walking  to  the 
doctor,  from  a  distance.  Facial  paralysis  is  not  always  present,  but  in 
its  absence  the  ''  risus  sardonicus  "  is  all  the  more  expressive  of  the 
diagnosis,  long  before  the  patient  has  complained  of  his  malady, 
especially  of  his  bitten  teeth. 

Fig.  44,  a  similar  case  to  fig.  43,  shows  the  facial  paralysis  better, 
there  being  complete  absence  of  folds  in  the  skin  on  the  left  side. 

If  these  somewhat  infrequent  causes  do  not  account  for  the  lock- 
jaw, it  is  necessary  to  determine  some  anatomical  causation. 

We  will  proceed  with  the  examination  in  the  natural  method.  If 
the  patient's  cheek  has  recently  become  swollen,  and  if  his  expression 
is  typical  of  toothache,  we  may  suspect  periostitis  of  the  jaw.  The 
mouth  is  opened  as  widely  as  possible,  and  the  offending  tooth,  which 
will  be  near  the  angle  of  the  jaw,  is  looked  for.  There  may  be  nothing 
wrong  to  be  detected  with  the  tooth,  but  the  fold  of  mucous  mem- 
brane between  the  jaw  and  the  cheek  will  be  more  or  less  obliterated. 

Instead  of  an  even  and  regular  swelling  of  the  cheek,  there  may 
6 


76 


SURGICAL   DISEASES   OF   THE    HEAD 


be  a  dense  infiltration,  with  sundry  sinuses,  foci  of  granulation  and 
fibrous  contractures,  reaching  down  as  far  as  the  neck  (fig.  46).  This 
will  at  once  suggest  actinomycosis.  The  pus  expressed  from  the 
sinuses  frequently  contains  the  well-known  yellowish  little  granules, 
of  the  size  of  millet  seeds,  which  serve  to  confirm  the  clinical  diag- 
nosis. 

We  shall  see   later  on   that    Actinomycosis  or  its   allied    Strepto- 
mycosis  may  also  begin  as  a  diffuse  swelling. 

Tuberculosis   of  the  jaw,  which  somewhat  resembles  the  above, 
occurs  but  rarelv.     The  first  glance  should,  however,  dift'erentiate  it, 

because  the  skin  is  less 
-       -         '  '       involved    and  because 

the  glands  are  consider- 
ablv  enlarged. 

If  the  lockjaw  has 
set  in  acutelv,  and  a 
diffuse  swelling  occu- 
pies the  whole  of  the 
lower  jaw  and  the  floor 
ofthe  mouth,  we  should 
think  of  osteomyelitis 
of  the  jaw. 

A  swelling  more 
closelv  confined  to  the 
cheeks,  Avith  tumid  lips 
and  a  foetid,  slightly 
sanious  fluid  issuing 
from  the  mouth,  points 
to  one  of  those  rare 
cases  of  gangrenous 
stomatitis.  Mcrcurinl 
s  to  111  a  i  if  is  m  av  pro- 
duce a  similar  clinical 
picture. 
If  the  aspect  of  the  patient  does  not  suggest  anv  cause  for  the  lock- 
jaw, we  must  examine  the  condition  of  the  articulation  of  the  jaw. 
A  rapid  and  painful  onset  of  the  trismus  will  make  us  think  of  acute 
arthritis,  which  occurs  in  the  most  varied  infective  diseases,  especially 
in  scarlet  fever,  acute  articular  rheumatism  and  gonorrhoea.  Tht 
region  of  the  joint  appears  somewhat  swollen,  pressure  in  front  of 
the  ear,  just  under  the  zygomatic  arch,  is  painful,  and  the  patient 
complains  of  radiating  pains  ni  the  neighbourhood  of  the  joint. 
Every  attempt  to  open  the  jaws  forciblv  produces  immediate  con- 
traction of  the  muscles  of  mastication.     If  there  are  no  acute  inflani- 


FiG.  43. — Head  tetanus.  The  patient  is  attempting  to 
open  his  mouth.  Contraction  of  right  side  ;  facial  palsy 
on  the  left.     Scar  over  left  lid. 


LOCK-JAW 


77 


matory  signs  and  the  lockjaw  is  of  old  standing,  but  has  followed 
some  acute  disease,  we  must  conclude  that  the  articulation  of  the 
jaw  has  become  ankylosed  through  some  antecedent  inflaniination. 
It  must  not  be  forgotten  that  ankylosis  of  the  jaw  can  develop 
in  the  course  of  a  chronic  ankylosing  polyarthritis. 

A  very  trifling  derangement  in  this  region  may  be  mentioned  here. 
It   consists  of  some  crepitation  in  the  joint  due  to  a  slight  looseness 
of  the  capsule  of  the  articular    cond^de   (termed   discitis,   by    Lanz). 
In    other    cases    this    crepi- 
tation    points     to     arthritis 
deformans  of  the  jaw,  which       ^ 
proceeds,  if  it  is  unilateral, 
to    cause    obliquity   of  the 
part,     with     corresponding 
obUquity  of  the  lower  teeth. 

Among  the  causes  of 
ank^dosis  of  the  jaAv  are 
inflammatory  processes  in 
the  neighbourhood,  which 
attack  the  jaw  secondarily. 
This  occurs  especially  in 
snppnirition  of  the  txnipanic 
cavity.  Injuries  also  play 
their  part,  for  they  may 
lead  to  bony  proliferation 
or  to  the  deyelopment  of 
osteomata. 

A  striking  smallness  of 
the  lower  jaw — a  bird  face 
— accompanying  the  lock- 
jaw, will  indicate  that  the 
disease  dates  from  infancy. 
Disuse  of  bone  leads  to 
atrophy,  and  therefore  the 
ankylosed  lower  jaw  fails 
to  grow  adequately. 

If  the  exhaustive  examination  of  the  joint  and  its  surroundings 
fails  to  discover  the  cause,  we  must  inspect  the  pharynx.  If  the 
disease  is  recent,  it  may  be  due  to  a  retro-tonsitlar  abscess,  if  chronic, 
it  ma}'  be  due  to  cicatricial  bands  in  or  under  the  mucous  membrane, 
or  to  a  malignant  neoplasm  near  the  tonsil. 


Fig.  44. — Head  tetanus,  with  facial  palsy. 
Small  wound  on  the  left  eyebrow. 


78  SURGICAL    DlSIiASES    OF   THE    HEAD 

CHAPTER   XIV. 
INFLAMMATORY    DISEASES    OF    THE    JAW. 

In  discussing  the  important  symptom  of  lock-jaw  in  the  preceding 
chapter,  we  have  ahTady  touched  upon  several  inflammatory  diseases 
of  the  jaw.  We  must  now,  however,  deal  with  them  again,  more 
systematically. 

(i)  Acute  psriostitis  of  the  jaw  which  is  always  the  result  of 
dental  disease,  presents  such  a  familiar  picture  that  its  consideration 
need  not  detain  us.  It  can  only  be  necessary  to  distinguish  it  from 
primary  osteomyelitis,  which  will  be  suggested  by  the  great  extent  of 
the  disease  and  inability  to  find  any  primary  lesion  in  the  teeth.  The 
course  of  this  disease  resembles,  in  its  severity,  acute  osteomyelitis  of 
the  extremities. 

(2)  The  chronic  inflammations  of  the  jaw  are  much  more  interest- 
ing. If  we  find  a  limited  area  of  disease,  for  instance,  a  sinus  m  the 
gum  or  on  the  cheek,  with  more  or  less  swelling  on  the  corresponding 
section  of  the  jaw,  we  may  be  sure  that  a  tooth  is  responsible  and  that 
the  condition  is  one  of  an  ordinary  dental  fistula  (tig.  45).  The  more 
contracted  the  neighbourhood  of  the  fistula,  the  longer  will  its  dura- 
ation  have  been.  If  there  is  no  tooth  in  the  affected  situation,  a  piece 
of  stump  will  probably  be  found  on  opening  the  alveolus,  or  in  an 
extensive  case,  a  scqiiesirimi  may  be  forthcoming.  If  the  removal  of 
such  causes  does  not  cure  the  inflammation,  some  more  serious  disease 
underlies  it,  and  we  shall  have  to  diagnose  between  actiuonycosis, 
tubercle,  and  phosphorus  necrosis. 

The  symptoms  of  actinouiycosis  of  the  jaw  have  been  briefly 
described  in  the  previous  chapter  ;  it  only  remains  to  add  that  the 
changes  at  the  site  of  infection — a  tooth  or  the  gum — are  so  com- 
pletely overshadowed  by  the  secondary  appearances  on  the  cheek  and 
neck,  that  it  frequently  becomes  impossible  to  define  the  spot  where 
the  infection  entered.  But  it  is  interesting  to  trace  the  source  of  iiifec- 
iion.  Usually  we  can  find  no  clue  in  the  case  of  the  town  dweller, 
and  in  country  districts  the  bad  habit  of  chewing  stalks  of  grass  is 
so  widespread  that  the  patient  is  most  unlikely  to  remember  any  such 
incident.  The  clue  is  more  definite,  if  one  can  ascertain  that  the 
patient  has  been  tending  cattle  with  actinomycosis,  as  once  occurred 
to  me  in  a  case  of  abdominal  actinomycosis. 

The  diagnosis  is  based  on  the  visible  external  changes  (figs.  46 
and  47),  on  the  dense  infiltration  with  brownish-red  foci  of  softening 
on  the  somewhat  contracted  cicatricial  areas,  on  the  absence  of  glandu- 


INFLAMMATORY   DISEASES    OF   THE   JAW 


79 


lar  enlargement,  and  finally  on   the    demonstration    of  the  yellowish 
little  granules. 

The  latter  may  be  confused  with  the  small  particles  of  necrotic 
tissue  which  sometimes  occur  m  tubercular  abscesses.  They  may, 
however,  be  pretty  clearly  distinguished,  even  without  the  microscope, 
m  the  following  manner  :  If  a  granule  of  the  ray  fungus  is  crushed 
between  two  glass  slides,  and  examined,  the  periphery  will  be  seen  to 
be  opaque  from  pus  cells,  while  the  centre  will  be  comparatively 
transparent,  being  occupied  by  the  interlacing  hbres  of  the  fungus. 
On  the  other  hand,  a  pus  coagulum,  or  a  particle  of  necrotic  tissue 
will  be  uniformly  turbid. 

When  all  the  described  signs  of 
actinomycosis  are  fully  developed, 
a  diagnosis  can  be  made  at  first 
sight,  even  if  the  characteristic 
granules  are  not  found.  But  on 
the  other  hand,  actinomycosis 
must  not  be  excluded  if  there  is 
only  a  purely  diffuse  swelling 
present,  without  the  skin  changes 
(fig.  46).  The  pus  should  be 
examined  for  the  rav  fungus 
(actinomycosis  or  streptomycosis) 
in  the  case  of  every  persistent 
chronic  abscess  of  the  jaw  with 
hard  edges.  If  the  immediate 
exammation  yields  a  doubtful 
result,  culture  tests  should  be 
undertaken. 

We  have  ali-eady  referred  to 
tuberculosis  of  the  jaw  among 
the  causes  of  lockjaw.  It  may 
appear  in   the  form  of  tubercular  Fig.  45.-Sinus  from  tooth. 

iLlcers  of  the  gum.  These  are  dia- 
gnosed by  their  sharp  margms,  chronic  course,  the  presence  of  enlarged 
soft  glands  in  the  neck,  and  the  failure  of  antisyphilitic  remedies.  To 
expedite  the  diagnosis,  it  is  necessary  to  scrape  away  a  piece  of  the 
margui  of  the  ulcer  with  a  sharp  spoon  and  it  will  generally  be  easy 
to  detect  tubercle  in  the  frozen  sections.  In  doubtful  cases  animal 
moculations  will  yield  a  decisive  result. 

The  early  stages  of  tubercular  disease  of  the  boue  itself  are  more 
difficult  to  recognize. 

The  folio  .ving  is  a  characteristic  case  :— 

A   woman,    aged    38,    gradually    became    affected    with    lockjaw. 
Already  at  the   first  examination  severe   swelling    of   the    cheek   and 


8o 


SURGICAL   DISEASES   OF   THE   HEAD 


t 


Fig.  46. — Early  stage  of  actinomycosis  of  jaw 
(before  the  bursting  of  abscess). 


temple  were  present.  Some  of 
the  molars  were  absent,  and  the 
others  did  not  appear  to  account 
for  the  clinical  condition,  more 
especially  as  the  bone  was  thick- 
ened, especially  about  the  angle 
of  the  jaw,  and  the  ascending 
ramus.  A  little  pus  exuded  from 
a  small  sinus  behind  the  last 
molar,  and  the  probe  impinged 
upon  bare  bone.  A  bunch  of 
movable  soft  and  elastic  en- 
larged glands  was  found  in  the 
neck 
temple  fluctuated 

Four  points  in  this  case  estab- 
lished the  diagnosis  forthwith: — 

(1)  The  insidious  onset,  which 
distinguished  the  disease  from 
an  ordinary  dental  periostitis. 

(2)  The  locahzation  on  the 
ascending  ramus,  which  is  not 
usual  in  dental  periostitis. 

(3)  The  obviously  tubercular 
glands  in  the  neck. 


The    swelling   over   the 


(4)  The  presence  of 
a  cold  abscess  over  the 
temple.  This  abscess,  which 
would  be  called  a  gravita- 
tion abscess  if  it  were  not 
making  its  way  upwards,  is 
quite  distinctive  of  tubercle 
of  the  lower  jaw.  Owing 
to  anatomical  reasons  the 
pus  cannot  find  its  way 
downwards ;  it  tracks  along 
the  line  of  least  resistance, 
between  the  pterygoids  and 
the  bone,  makes  its  way 
upwards  and  gets  beneath 
the  temporal  muscle.  The 
temporal  bone  and  other 
bones  of  the  skull  may  be 
attacked  secondarily  as  a 
result  of  this  abscess. 


Fig.  47. — Actinomycosis  of  jaw.      (Advanced  stage.) 


INFLAMMATORY   DISEASES    OF   THE   JAW  8 1 

The  subsequent  progress  of  the  above  case  was  also  very  dis- 
tinctive. 

The  abscess  was  opened  from  the  mouth,  a  tubercular  sequestrum 
was  removed  from  the  ascending  ramus  and  the  bony  cavities  were 
scraped  out.  But  this  only  gave  temporary  relief.  Before  the  disease 
was  checked  it  was  necessary  to  resect  the  whole  of  the  ascending 
ramus,  and  subsequently  a  portion  of  the  horizontal  ramus.  The 
tubercle  afterwards  invaded  the  upper  jaw,  and  this  had  to  be  resected; 
and  two  years  later  the  patient  had  ileo-sacral  tuberculosis  of  both 
sides. 

Most  cases  of  tubercle  of  the  jaw,  hitherto  described,  have  run  a 
similar  course. 

Phosphorus  necrosis  presents  a  different  picture  altogether,  the 
trouble  also  begins  with  msignificant  symptoms  of  toothache,  but 
the  extraction  of  the  painful  teeth  does  no  good.  The  pain  persists, 
one  acute  abscess  after  another  appears  and  they  burst,  either  through 
the  gum  or  externally,  leaving  permanent  fistulse.  The  whole  jaw 
becomes  diffusely  thickened  through  the  formation  of  new  bone  from 
the  periosteum,  and  finally  a  piece  of  the  original  jaw  extrudes  itself — 
the  whole  lower  jaw  may  indeed  become  necrosed — and  is  easily 
removed  by  the  patient  himself  or  the  medical  attendant. 

In  both  phosphorus  necrosis  and  osteomyelitis  of  the  jaw  exten- 
sive sequestra  may  form  ;  but  in  phosphorus  necrosis  this  process 
does  not  develop  from  one  sudden  attack,  but  is  the  result  of  slow 
stages.  Tubercle  is  similar  to  phosphorus  necrosis  in  its  chronicity, 
but  the  latter  differs  completely  in  the  large  extent  of  sequestrum 
formation.  The  only  similarity  between  phosphorus  necrosis  and 
actinomycosis  is  also  their  chronicity.  But  the  former  always  remains 
a  bone  disease  despite  abscesses  in  the  soft  tissues  and  despite  fistulae  ; 
in  actinomycosis  the  affection  of  the  bone  assumes  minor  importance 
and  the  disease  of  the  soft  parts  predominates.  It  is  obvious  that  it 
must  be  shown  that  the  patient  has  had  long  contact  with  phosphorus 
in  order  to  confirm  the  diagnosis  of  phosphorus  necrosis.  But  it 
must  not  be  forgotten  that  the  disease  may  arise  many  ^^ears  after  the 
patient  has  ceased  to  be  imder  the  influence  of  phosphorus. 
Phosphorus  necrosis  might,  happily,  become  merely  a  matter  of 
history,  if  new  spheres  for  the  employment  of  yellow  phosphorus  in 
industry  were  not  being  opened  up. 


82 


SURGICAL    DISEASES    OF   THE    HEAD 


CHAPTER   X\^ 


TUMOURS    OF   THE   UPPER   JAW. 

Tumours  of  the  upper  jaw  are  imitated  by  harmless  conditions, 
just  as  are  so  many  malignant  diseases,  a  circumstance  responsible 
for  delayed  diagnosis.  Periostitis  of  the  jaiv  and  chronic  inftmnniation 
of  the  maxillary  sinus  are  the  principal  ones,  A  swelling  in  the  upper 
jaw,  coming  on  with  toothache,  sends  the  patient  at  first  to  the  dentist, 
and  a  few  teeth  are  extracted.     If  he   is  disturbed  by  unusual  nasal 

_  discharge    or    by    the 

obstruction  of  a  nos- 
]  tril,  he  consults  a  nose 
'  specialist  to  get  his 
antrum  washed  out. 
The  patient  is  fortu- 
nate if  it  is  recognized 
that  his  case  does  not 
belong  to  those  speci- 
alities, but  concerns 
the  surgeon.  This 
summary  diagnosis  is 
not  difficult  if  one 
appreciates  the  maxim 
that  any  sivelling  of 
the  upper  jaiv,  lioivever 
small,  accompanied  by 
p  e  rs  i  stent  neuralgic 
pains,  must  be  sus- 
pected of  a  nialiguaucy. 
Other  symptoms  may 
be  entirely  absent,  such 
as  displacement  of  the 
nose,  a  sanio-purulent 


Fig.  48. — Carcinoma  of  upper  jaw. 


discharge  from  the  antrum,  deviation  of  the  eye  (squint,  double  vision), 
ulceration  into  the  oral  cavity  or  vestibule  of  the  mouth.  Nevertheless, 
there  can  be  no  doubt  of  the  diagnosis,  if  on  comparing  both  sides  it  is 
found  that  the  canine  fossa  is  somewhat  obliterated,  the  lower  orbital 
margin  spherical  or  irregular,  the  floor  of  the  orbit  perhaps  already  raised, 
and  if  the  neuralgia  is  of  infra-orbital  character  ;  especially  if  one  of 
the  other  symptoms  just  mentioned  is  also  present.  To  confirm  the 
diagnosis,  some  of  the  diseased  tissue  should  be  removed  with  a  sharp 
spoon  from  the  antrum,   either  through  the  nose,   or  by  making  a 


TUMOURS    OF   THE   UPPER   JAW 


83 


small  incision  and  opening  the  antrum  from  the  vestibule  of  the 
mouth.  The  piece  removed  must  be  submitted  to  histological  ex- 
amination, which  will  at  the  same  time  reveal  the  intimate  structure 
of  the  growth.  Clinical  diagnosis  cannot  go  beyond  declaring  the 
presence  of  a  iiialigiiaiit  growth,  it  cannot  define  its  histological  details. 
Theoretically  we  should  expect- that  a  tumour  which  at  first  is  confined 
within  the  antrum  and  then  gradually  breaks  through  its  wall  is  more 
likely  to  be  a  periosteal  sarcoma — a  growth  which  rapidly  makes  its 
way  externally — than  a  squamous  epithelioma.  Experience,  how- 
ever, shows  that  the  very  opposite  may  occur.  Sometimes  sarcomata 
are  limited  to  the  an- 
trum for  months,  and  [ 
squamous  epitheliomata 
may  proliferate  so  rapidly 
towards  the  surface  that 
warm  poultices  are 
ordered  on  the  assump- 
tion that  the  swelling  is 
due  to  periostitis.  Palpa- 
tion aft'ords  no  conclu- 
sive evidence.  In  the 
case  of  tumours  of  the 
upper  jaw  it  is  not  pos- 
sible to  rely  on  the  dis- 
tinction that  firm  nodular 
growths  are  generally 
cancerous,  and  that  round, 
elastic  growths  are  usually 
sarcomatous.  Early  en- 
largement of  the  glands 
is  more  important  for  the 
diagnosis  of  cancer,  but 
this  sign  is  often  absent. 

But  the  practitioner  is 
under  no  obligation  to  worry  himself  over  the  dift"erential  diagnosis. 
He  has  done  his  duty  if  he  has  sent  the  case,  in  an  early  stage,  to 
the  surgeon  as  one  of  malignant  growth.  From  the  operative  point 
of  view  it  is  immaterial  whether  it  be  sarcoma  or  carcinoma.  There 
is,  however,  a  great  difference  in  the  prognosis,  as  the  ultimate  results 
of  operations  on  sarcomata  of  the  upper  jaw  are  much  better  than 
those  on  carcinomata. 

As  we  have  already  mentioned,  difficulties  of  diagnosis  may  arise 
from  empyema  of  the  antrum,  periostitis  of  the  jaiv,  tuberculosis  of  the 
jaiv,  and  deutal  cysts.  Each  one  of  these  diseases  has  its  characteristic 
previous  history. 


Fig.  49.— Dental  cyst  on  upper  jaw.     The  right  lateral 
incisor  is  absent  below  the  cyst. 


84 


SURGICAL   DISEASES   OF   THE    HEAD 


In  chronic  empyema,  the  most  striking  incident  is  the  periodical 
discharge  of  pus.  As  long  as  the  discharge  is  free  there  is  absolutely 
no  pain,  but  when  it  is  retained,  there  is  a  neuralgia  of  racking,  beating, 
and  sometimes  of  a  boring  character.  There  is  also  local  pain  on 
pressure  in  the  stage  of  retention.  Duiing  the  intermediate  stage,  the 
pain  is  dull  and  quite  tolerable.  But  in  the  case  of  malignant 
growths  the  pain  is  severe  and  tormenting  and  allows  of  no  respite, 
even  when  there  is  no  external  sign  of  irritation  or  anv  marked  pain 
on  pressure.  There  is  sometimes  a  purulent  discharge  in  carcinoma, 
and  this  may  lead  to  the  mistaken  diagnosis  of  oi'dinarv  antrum 
disease.     But  the  fact  that  there  is  so  much  pain  in  the  presence  of 

a  free  discharge  must  arouse  the  sus- 
picion of  a  malignant  neoplasm. 

It  is  usually  easy  to  detect  the 
ofi'ending  tooth  in  a  case  of  peri- 
ostitis of  the  jaw.  Malignant  tumours 
produce  toothache  in  teeth  which 
are  otherwise  healthy.  The  pain 
also  involves  the  cutaneous  branches 
of  the  nerves  (upper  lip)  and  is  fre- 
quently accompanied,  by  anaesthesia 
(anaesthesia  dolorosa).  In  both  peri- 
ostitis of  the  jaw  and  in  empyema  of 
the  jaw,  the  pain  is  only  present  in 
the  acute  stage,  or  in  acute  exacer- 
bations, and  it  becomes  relieved  either 
spontaneously  or  after  appropriate 
treatment.  One  special  form  of 
ostitis  can  give  rise  to  very  serious 
difticulties  in  diagnosis,  namely, 
tuberculosis  of  the  jaw.  Its  charac- 
teristics have  been  mentioned  above. 
In  cases  of  cysts  of  the  jaw,  there  is  a  gradual  enlargement  of  the 
bone,  which  eventually  crumbles  like  parchment,  but  there  is  usually 
no  pain  as  long  as  the  contents  of  the  cysts  are  not  infected.  In  some 
cases  they  emptv  themselves  periodically  through  the  nose  and  then 
fill  up  again.  They  may  persist  for  years,  a  circumstance  which 
differentiates  them  from  malignant  growths,  for  both  in  carcinoma 
and  in  sarcoma,  the  diagnosis  can  generally  be  firmly  established 
within  a  few  months  of  the  onset  of  symptoms.  If  one  tooth  is 
missing  from  the  set  and  is  seen,  on  the  skiagram,  in  the  tumour,  all 
doubt  is  dispelled  {see  figs.  49  and  50). 

If  we  meet  with  the  symptoms  of  a  malignant  growth  of  the  upper 
jaw  in  an  adolescent  male,  we  must  also  think  of  a  nasopharyngeal 


Fig.  50. — Skiagram  of  fag.  49.     X,  Dental 
cyst  with  the  missing  incisor  tooth,  Z. 


TUMOURS    OF   THE    LOWER   JAW  85 

fibroma.  This  growth  springs  from  the  base  of  the  skull  near  the 
roof  of  the  pharynx  and  penetrates  into  all  accessible  fissures,  especially 
into  the  nose,  the  orbit,  and  circuitously,  into  the  parotid  region  and 
the  maxillary  sinus. 

I  have  seen  a  case  wherein  the  tumour  penetrated  thence  into  the 
mouth  cavity  and  began  to  putrefy.  This  peculiar  course  at  once 
suggested  sarcoma.  Histological  examination  and  further  progress, 
showed,  however,  that  it  was  an  ordinary  nasopharyngeal  fibroma. 
The  patient  made  a  good  recovery,  although  the  tumour  was  not 
completely  extirpated  from  the  base  of  the  skull,  it  only  being  possible 
to  burn  it  away  with  the  thermocautery. 

Innocent  tumours  of  the  body  of  the  upper  jaw,  apart  from 
dental  cysts,  are  so  rare  that  they  do  not  enter  seriously  into  the 
question  of  differential  diagnosis.  They  behave  like  the  correspond- 
ing grow^ths  of  the  lower  jaw,  the  description  of  which  should  be 
referred  to. 

On  the  other  hand,  innocent  tumours,  or  gron'tlis  only  nialignant 
locally,  play  the  most  important  part  in  connection  with  the  alveolar 
process.  These  will  be  discussed,  together  with  the  growths  of  the  oral 
cavity. 


CHAPTER  XVI. 

TUMOURS  OF  THE  LOWER  JAW. 

Apart  from  neoplasms  of  the  gums  and  alveolar  process,  which 
we  shall  discuss  in  connection  with  tumours  of  the  oral  cavity,  new 
growths  of  the  lower  jaw  present  no  difticulties  of  recognition.  Care 
must  be  taken,  however,  not  to  confuse  a  swelling  which  appears  to 
be  a  tumour,  with  what  is  really  an  inflammatory  process.  We  must 
abandon  the  thought  of  a  new  growth,  and  conhne  ourselves  to  one 
of  the  inflammatory  conditions  described  in  Chapter  XIV,  if  the 
disease  has  started  with  toothache,  caused  by  carious  teeth  which  are 
in  evidence  ;  if  the  thickening  of  the  jaw  has  been  preceded  by  an 
iicute  inflammatory  stage  ;  if  the  patient  tells  of  repeated  acute  exacer- 
bations and  shows  the  scar  of  an  old  dental  fistula  in  testimony 
thereof  ;  or  if  wc  find  tubercular  glands  of  the  neck  in  a  purely 
chronic  disease.  We  are,  how'ever,  justified  in  diagnosing  torthw'ith 
a  new^  growth,  if  the  swelling  has  come  on  gradually  and  painlessly  ; 
if    t(jothache,   when   present,    is    a    late    symptom,    and    healthy    teeth 


86 


SURGICAL   DISEASES   OF   THE    HEAD 


become  loose  without  any  visible  inflammatory  changes  in  the  gum. 
Palpation  will  sometimes  elucidate  the  condition.  An  inflammatory 
swelling  gradually  merges  with  the  healthy  bone,  whereas  most 
tumours  appear  to  be  sharply  separated  therefrom.  Central  tumours 
form  an  exception  to  this  rule,  because  these,  at  first,  expand  the  bone 
in  a  spindle-shaped  manner.  In  these  cases,  the  exclusion  of  any 
antecedent  dental  disorder  is  decisive  from  the  point  of  view  of 
diagnosis. 

Having  concluded  that  a  growth  is  present,  the  first  question 
concerns  its  innocence  or  malignancy.  The  history  supplies  the 
critical  factor,   because  a  slow  growth  always  means  innocence,  and 

a    rapid    growth    signifies 
f~  ^     malignancy.     But  this  cri- 

terion must  be  cautiously 
applied,  because  even  a 
sarcoma  may  last  for  many 
years.  It  is  necessary,  next, 
to  consider  the  matter 
of  painfulucss.  Painless 
tumours,  which  remain 
painless  for  years,  are  inno- 
cent. If  toothache  comes 
on,  a  suspicion  of  malig- 
nancy arises,  but  only 
suspicion,  for  innocent 
growths  may  cause  neu- 
ralgia by  pressure  on  the 
inferior  dental  nerve.  On 
the  other  hand,  victims  of 
sarcoma  may  remain  free 
from  pain  for  a  consider- 
able time.  It  is  only  in 
extreme  cases,  therefore,, 
that  the  previous  history 
permits  of  the  formation  of  an  immediate  diagnosis.  In  intermediate 
cases  every  clinical  aid  will  need  to  be  enlisted,  and  often  enough 
the  microscope  will  be  required  to  make  the  final  decision.  It  must 
not  be  forgotten  that  a  tumour  which  has  been  innocent  for  years 
may  eventually  become  malignant.  This  change  can  generally  be 
recognized  by  sudden  rapidity  of  growth. 

We  have  purposely  omitted  one  sign,  viz.,  the  absence  or  presence 
of  metastases  in  the  glands  of  the  neck,  because  this  is  not  a  matter 
of  significance  in  connection  with  tumours  of  the  lower  jaw.  Malig- 
nant growths  in  this  situation  are  sarconuita,  which  usually  leave  the 
glands  unaffected.     Enlarged  glands  should  therefore  not  be  regarded 


Fig.  51.  —  Odontoma  of  lower  jaw. 


TUMOURS    OF   THE    LOWER   JAW  8/ 

as  a  mark  of  malignancy,  but,  as  previously  stated,  rather  an  indication 
of  tubercular  disease. 

We  now  proceed  to  discuss  the  individual  varieties  : — 
(i)  The  first  group  of  growths  of  the  lower  jaw  embraces  tumours 
connected  in  some  manner  with  the  developnieni  of  the  teeth,  or  at  any 
rate  with  the  epithelial  covering  of  the  jaw.  They  are  not  indeed  of 
frequent  occurrence,  but  they  are  of  great  theoretical  interest.  Among 
these  are  dental  cysts,  which  appear  during  the  period  of  youth  ;  they 
push  the  jaw  oiitivards,  and  they  contain  either  a  tooth  which  is 
missing  from  the  series,  or  a  supernumerary  tooth.  The  expansion  of 
the  jaw  which  they  cause  is  very  gradual,  so  that  finally  the  bone 
gives  the  crumbling  sensation  peculiar  to  parchment.  If  such  a  cyst 
has  been  incised  in  ignorance  of  its  true  nature,  or  if  it  has  burst 
spontaneously,  a  fistula  remains  which  is  very  prone  to  secondary 
infection,  wherewith  the  whole  aspect  of  the  case  is  obliterated. 
Another  group  consists  of  odontoma  and  adamantinoma.  These  may 
be  soft,  or  as  hard  as  enamel,  or  of  a  mixed  character.  They  arise  in 
young  people  as  an  irregular  proliferation  of  the  various  elements  of 
a  tooth,  and  they  gradually,  but  painlessly,  displace  the  enclosing  bone, 
both  ontward  and  imvards.  Their  favourite  site  is  in  the  neighbour- 
hood of  the  posterior  molars  (fig.  51).  Another  tumour,  less  associated 
with  tooth  development,  is  the  multilocular  cystoma  of  jaw,  in  which 
the  bone  becomes  gradually  expanded  by  cystic  proliferation  of  its 
epithelial  covering,  and  finally  becomes  converted  into  a  vesicular 
shapeless  structure.  This  change  eventually  attacks  the  ascending 
ramus  of  the  jaw,  in  contrast  to  what  occurs  in  simple  cysts  of  the  jaw 
and  odontomata. 

(2)  Turning  novv^  to  connective  tissne  tnmonrs,  we  must  mention 
the  innocent  groivths,  fibroma,  chondroma  and  osteoma,  as  of  com- 
paratively rare  occurrence.  If  they  arise  from  the  surface  of  the  bone, 
they  grow  slowly,  their  structure  is  nodular,  they  feel  firm  or  hard, 
and  only  become  troublesome  through  secondary  changes.  But  if 
they  exist  within  the  bone,  their  pressure  on  the  inferior  dental  nerve 
may  soon  produce  neuralgia.  The  bone  is  expanded,  first  in  a 
spindle-shaped  manner,  and  having  reached  the  surface  it  appears  as 
a  nodular  sharply  defined  structure. 

Sarcomata,  malignant  connective  tissne  tnmonrs,  play  the  chief 
role  among  the  tumours  of  the  lower  jaw.  The  initial  symptoms  and 
■early  discomfort  depend  upon  whether  their  site  is  central  or  peri- 
pheral ;  but  their  course  is  more  rapid  than  that  of  the  tumours 
-previously  discussed,  even  if,  exceptionally,  the  first  signs  date  some 
years  back. 

The  following  observation  is  very  significant  : — 

A  female,  aged  50,  came  to  her  medical  attendant  complaining  of 


88  SURGICAL    DISEASES    OF   THE    HEAD 

a  gradual  thickening  of  the  riglit  horizontal  ramus  of  the  lower  jaw. 
It  was  regarded  as  a  dental  cyst  and  was  opened  from  the  mouth. 
The  knife  penetrated  into  a  hollow  space,  from  which  a  profuse 
stream  of  blood  flowed.  I  saw  the  patient,  two  years  later,  with  a 
diffuse  expansion  of  the  whole  right  half  of  the  jaw.  The  diagnosis 
pointed  to  sarcoma,  and  the  operation  consisted  of  removing  half 
of  the  jaw,  which  was  expanded  as  far  as  the  articular  process  into 
vesicular  cavities,  just  like  a  multilocular  cystoma  of  the  jaw.  The 
small  amount  of  firm  tissue  present  showed  the  structure  of  a  round 
celled  sarcoma.  Two  years  subsequently  I  saw  the  patient  again. 
Locally  she  was  cured,  but  there  were  secondary  deposits  of  similar 
structure  in  the  skull  and  sternum. 

The  diagnosis  may  be  difficult  in  the  early  stages,  as  already 
intimated,  but  it  cannot  be  missed  if  the  tumour  has  proliferated 
into  the  oral  cavity,  has  caused  the  teeth  to  fall  out,  has  become 
adherent  to  the  skin,  or  has  finally  ulcerated  to  one  side  or  another. 
It  should,  however,  not  be  allowed  to  reach  such  a  degree  ;  every 
tumour  of  the  jaw  which  does  not  remain  quite  stationary,  ought 
to  be  suspected  and  removed. 

A  careful  examination  will  generally  reveal  the  starting  point  of 
the  tumour,  notwithstanding  many  exceptions.  The  sensation  of 
crinkling  like  parchment  indicates  a  central  site,  as  also  does  a  bony 
resistance  of  the  surface,  detected  by  the  acupuncture  needle.  If 
acupuncture  is  made  in  various  places  and  bone  is  only  struck  at 
a  great  depth,  the  growth  has  arisen  from  the  periosteum.  But 
nowadays  Rontgen-ray  examination  should  replace  acupuncture, 
because  a  skiagram  gives  a  clearer  conception  of  the  distinction 
between  bony  and  soft  tumours,  and  also  reveals  the  missing  tooth 
in  the  case  of  dental   cysts   (figs.   49  and  50). 

We  have  said  nothing  about  cancer  of  the  lower  jaiv,  but  this  will 
be  referred  to  in  the  next  chapter,  as  it  usually  grows  from  the  mucous 
membrane  of  the  gums.  Isolated  masses  of  dental  epithelium,  deeply 
displaced,  very  rarely  undergo  cancerous  degeneration. 


CHAPTER  XVII. 


ACUTE    INFLAMMATORY   DISEASES    OF   THE 
ORAL    CAVITY. 

We  have  already  met  with  some  of  the  acute  inflammatory  diseases 
of  the  interior  of  the  mouth,  and  we  shall  come  across  them  again 
when  we  discuss  some  of  their  main  symptoms  :  lockjaw  and  difficulties 
in  swallowing  and  breathing.  We  shall,  therefore,  here  only  collate 
a  few  points  which  have  been  treated  disconnectedly,  and  supply^ 
sundry  omissions. 


ACUTE    INFLAMMATORY    DISEASES    OF   THE    ORAL    CAVITY  89 

An  acute  swelling  of  the  lips  nearly  always  depends  upon  the 
presence  of  a  small  furuncle,  w^hich  may  have  disappeared  in  the 
general  oedema,  assuming,  of  course,  that  the  swelling  is  not  a  part 
of  an  extensive  inflammation  like  erysipelas,  or  the  result  of  a  perios- 
titis of  the  jaw.  We  have  already  noted  the  possible  dangers  of  a 
furuncle  of  the  lip. 

Annciife  ciicnmscrlbecl  swelling  of  the  ginn  indicates  either  a  diseased 
tooth  or  a  root  retained  in  the  alveolus.  The  precise  localization  is 
shown  by  the  position  of  the  most  intense  redness  of  the  mucous 
membrane,  and  the  greatest  obliteration  of  the  fold  between  the  cheek 
and  jaw.  If  the  offending  tooth  is  still  visible,  it  will  readily  respond 
to  light  percussion. 

Acute  widespread  swelling  of  the  gum  is  a  sign  of  some  form  of 
acute  periostitis  of  the  jaw  {see  lower  jaw),  or  of  a  general  stomatitis 
(see  below). 

Acute  swehing  of  the  floor  of  the  moiilli  may  be  due  to  many 
causes.  If  the  swelling  is  in  the  middle  line,  and  more  definite 
posteriorly  than  anteriorly,  w^e  should  think  of  a  secondarily  sup- 
purating dermoid,  which  is  common  in  children,  or  of  an  inflamed 
lymphangioma.  In  such  a  case  an  adult  would  observe  that  there 
had  been  something  abnormal  under  the  tongue  before  the  onset  of 
the  acute  inflammation. 

If  the  inflammation  has  proceeded  externally  towards  the  sub- 
mental region,  the  case  is  one  of  phlegmonous  submental  lympha- 
denitis, A  sore  on  the  lip,  an  acute  pustule,  a  small  infected  abrasion 
of  the  skin,  will  have  afforded  the  portal  of  entry  of  the  infection. 

If  the  swelling  on  the  floor  of  the  mouth  is  rather  unilateral,  or 
if  the  patient  can  state  on  which  side  it  began,  acute  inflammation 
of  the  salivary  glands  must  be  thought  of.  If  the  swelling  is  anterior, 
the  sublingual  gland  is  affected,  if  lateral,  it  is  the  submaxillary  gland. 
In  these  cases  the  floor  of  the  mouth,  in  the  vicinity  of  the  gland, 
may  look  like  a  translucent  oedema  and  the  swelling  feel  like  a  board. 
The  cause  of  the  swelling  will  be  found  in  a  salivary  calculus,  especially 
if  the  patient  states  that  he  has  suffered  from  repeated  attacks  of 
such  inflammation.  If  these  exacerbations  are  of  short  duration,  and 
terminate  with  a  discharge  of  saliva,  there  is  no  doubt  the  swelling 
indicates  salivary  retention.  If  they  are  of  longer  duration — a  day 
or  more — and  increasing  infiltration  of  the  tissue  takes  place,  we 
must  conclude  that  some  bacterial  inflammation  of  the  salivary  glands 
has  become  engrafted  on  the  simple  retention.  If  treatment  is  not 
undertaken,  the  swelling  will  proceed  to  its  natural  result — the  forma- 
tion of  an  abscess. 

If  the  symptoms  are  distinctly  inflammatory  from  the  start  and 
are  better   developed  externally  than  towards   the  mouth  cavity,  the 


90  SURGICAL   DISEASES   OF   THE    HEAD 

case  is  one  of  acute  submaxillary  lymphadenitis.  Its  cause  will 
most  probably  be  found  on  the  gum,  or  the  cheek,  or  nose  if  the 
portal   of  entry  still  remain  demonstrable. 

If  the  infection  is  very  severe,  and  tends  to  spread,  especially 
towards  the  floor  of  the  mouth,  it  is  termed  "  Ludwig's  angina," 
which  is  merely  a  clinical  and  not  an  etiological  indication.  The 
exciting  causes,  as  usual  about  the  mouth,  are  staphylococci,  strepto- 
cocci and  colon  bacilli.  The  great  severity  of  the  infection  strongly 
suggests  that  the  infection  arises  from  some  deep  focus — directly 
around  the  submaxillary  gland. 

If  the  swelling  involves  the  tongue  from  the  start,  and  this  organ 
quickly  becomes  converted  into  a  dense  immovable  mass,  with  saliva 
trickhng  from  the  open  mouth  of  the  patient,  who  can  neither  swallow 
nor  speak,  but  can  just  breathe,  the  case  is  one  of  acute  glossitis, 
which  usually  ends  with  the  formation  of  a  lingual  abscess.  This 
rare  disease  is  of  a  metastatic  character,  and  supervenes  especially  as 
a  sequela  of  acute  infectious  diseases.  If  in  the  course  of  glossitis 
thei'e  be  dyspnoea  with  delayed  respiration  and  stridor,  it  is  obvious 
that  the  larynx  has  become  oedematous,  and  that  tracheotomy  is 
urgently  required.  If,  on  the  other  hand,  the  dyspncea  is  accom- 
panied by  cyanosis  and  hurried  respiration,  without  stridor,  we 
conclude  that  aspiration  pneumonia  has  supervened,  and  our  pro- 
gnosis will  be  correspondingly   doubtful,  if  not  bad. 

Sometimes  the  entire  floor  of  the  mouth  is  involved  in  a  phleg- 
monous inflammation  from  the  very  beginning ;  and  the  tongue, 
which  is  usually  oedematous  at  the  same  time,  is  pressed  against  the 
palate.  The  clinical  picture  resembles  that  of  Ludwig's  angina,  but 
is  bilateral  from  the  start.  This  constitutes  a  case  of  acute  phlegmon 
of  the  floor  of  the  mouth,  and  has  three  sources  of  danger — 
(i)  suffocation,  (2)  aspiration  pneumonia,  and  (3)  extension  of  the 
inflammation  to  the  connective  tissue  of  the  neck  and  mediastinum. 

If  the  original  site  of  the  swelling  be  the  istJunus  of  the  fauces,  the 
first  glance  will  suffice  to  distinguish  between  diffuse  and  ■uuilateral 
sore  throat.  If  it  be  diffuse,  we  must  think  of  catarrhal  and  lacunar 
sore  throat,  scarlet  fever,  diphtheria,  and  secondary  syphilis.  As  far 
as  these  are  of  surgical  importance,  they  will  be  discussed  later  on 
with  the  subject  of  diphtheria. 

The  inexperienced  often  miss  syphilitic  soi-e  throat  when  it  appears 
in  a  mild  catarrhal  form,  and  is  not  accompanied  by  mucous  patches 
on  other  parts  of  the  mucous  membrane.  Those  affected  with 
"syphilis  insontium "  are  of  course  unaware  of  its  cause,  and  the 
others  often  enough  refuse  to  know  anything  about  it.  But  it  is 
just  in  this  stage  that  diagnosis  is  so  important,  both  because  of  early 
treatment  and  the  protection  of  the  patient's  surroundings. 

If  the  sore  throat  is  unilateral,  we  should  entertain  the  possibility 


TUMOURS   AND   ULCERS    IN   THE   MOUTH,  PHARYNX   AND   NOSE       91 

of  a  tonsillar  or  retro-tonsillar  abscess.  If  the  swelling  increases, 
we  should  not  wait  till  it  bursts  spontaneously,  but  should  search  for 
pus  in  the  classical  situation  before  complications  supervene. 

An  acute  swelling  on  the  posterior  or  lateral  wall  of  the  pharynx 
must  be  regarded  as  an  acute  retropharyngeal  abscess,  which  is 
generally  due  to  a  lymphadenitis,  but  in  rare  cases  may  depend  upon 
osteomyelitis  of  the  spine.  If  the  abscess  is  not  accessible  externally 
we  must  evacuate  it  from  the  inside,  using  a  puncture  syringe  so  that 
the  gush  of  pus  should  not  inundate  the  larynx. 

Further,  we  must  not  forget  that  there  are  certain  acute  in- 
flammatory processes  which  lead  to  the  growth  of  adenoids  on  the 
roof  of  iJie  pharynx.  The  examination  of  this  region  is  always  im- 
portant when  children  suffer  from  unexplained  pyrexia. 

If  the  lips  and  cheeks  are  infiltrated,  and  a  diffuse  swelling  of  the 
mucous  membrane  with  severe  turgidity  of  the  gums  is  seen  when 
the  mouth  is  opened — as  far  as  the  lockjaw  permits  this — if  there  are 
already  a  few  ulcers  about,  and  foetid  froth  issues  from  the  mouth,  we 
are  confronted  by  the  rare  disease  gangrenous  stomatitis,  which 
may  be  fatal  in  a  few  days,  but  the  cause  of  which  is  still  obscure. 
This  disease  exhibits,  in  the  most  intense  degree,  the  symptoms  present 
in  scurvy  and  mercurial  stomatitis. 

If  the  inflammatory  process  is  so  severe  that  gangrene  of  the  lips 
and  cheeks  ensues,  it  is  impossible  to  miss  the  clinical  picture  of 
noma,  which  occasionally  attacks  children  after  debilitating  infectious 
diseases. 


CHAPTER   XVIII. 

TUMOURS   AND   ULCERS    IN  THE   MOUTH, 
PHARYNX  AND    NOSE    CAVITIES. 

Many  new  growths  of  mucous  membrane  appear  as  ulcers  ;  we 
must  therefore  discuss  them  in  common,  when  dealing  with  the  oral 
and  pharyngeal  cavities.  We  have  previously  stated  that  every  obstinate 
nicer  must  be  suspected  of  uialiguaucv,  however  little  aspect  of  growth 
it  may  possess.  If  this  maxim  were  adequately  taken  to  heart  we 
should  not  so  often  see  carcinoma  treated  for  weeks  with  lunar  caustic, 
until  the  enlargement  of  the  glands  of  the  neck  finally  takes  the  con- 
firmed optimist  by  surprise,  but  renders  the  issue  of  an  operation 
doubtful. 


92  SURGICAL   DISEASES    OF   THE    HEAD 

/I.— NON-ULCERATING   GROWTHS. 

We  only  include  here  among  "ulcerating  growths  "  those  wherein 
ulceration  is  of  the  essence  of  the  disease,  such  as  cancer,  tubercle  or 
syphilis,  but  not  those  which  have  been  exposed  to  accidental  super- 
ficial erosion,  e.g.,  an  epulis  wounded  by  an  adjacent  tooth.  In  cases 
of  cancer  it  is  often  necessary  to  look  for  the  ulcer.  A  cancer  at  the 
base  of  the  tongue  may  start  as  a  non-ulcerating  growth,  and  only 
after  a  careful  examination  with  a  mirror  or  the  palpating  finger,  will 
a  deep,  open  excavation  be  discovered  posteriori}^ 

We  shall  proceed  topographically,  because  the  various  diseases 
have  their  own  special  sites  of  preference. 

(1)  THE    MUCOUS    MEMBRANE    OF   THE    LIPS   AND 

CHEEKS. 

If  a  patient  complains  of  a  little  tumour  about  the  size  of  a  hazel 
nut,  situated  in  the  mucous  membrane  of  the  lip  or  cheek — a  tumour 
which  disappears  and  reappears,  and  examination  reveals  a  bluish 
translucent,  semi-globular  structure  which  is  not  dispelled  by  pressure, 
the  diagnosis  can  only  be  a  mucous  cyst.  But  if  the  tumour  in  this 
situation  is  bluish-red,  and  is  dispelled  by  pressure  of  the  finger,  the 
case  can  be  nothing  but  one  of  cavernous  angioma.  It  is  noteworthy 
that  the  angiomata  of  the  mucous  membrane,  in  contrast  to  those  of 
the  skin,  are  distinctly  encapsuled.  A  soft  pedunculated  growth,  which 
cannot  be  dispelled  by  pressure,  hanging  from  the  mucous  membrane 
of  the  cheek  is  a  fibroma,  in  which  the  various  components  of  the 
mucous  membrane,  viz.,  glands,  blood-vessels  and  h'mphatics,  are 
more  or  less  extensively  proliferated. 

(2)    THE    FLOOR    OF   THE    MOUTH. 

The  tumours  in  this  region,  covered  by  normal  mucous  membrane, 
are  usually  cystic  structures,  except  for  the  very  rare  yellowish  lobulated 
lipomata  which  are  visible  beneath  the  mucous  membrane.  The 
surgeon  did  not  note  the  yellowish  colour  of  the  swelling,  depicted 
in  fig.  52,  and  he  incised  it,  thinking  it  was  a  ranula. 

A  bluish  tumour,  rather  laterally  situated,  shining  through  the 
thinned  mucous  membrane,  soft,  elastic,  or  fluctuating  in  consistence, 
and  raising  the  tongue,  is  a  ranula.  This  diagnosis  states  nothing  as 
to  the  origin  of  the  structure  concerning  which  embryologists  and 
surgeons  are  at  considerable  variance.  The  view  at  present  prevailing 
explains  most  cases  on  the  assumption  that  they  arise  as  cysts  from 
segments  of  the  sublingual  gland,  much  in  the  same  way  as  the 
mucous  cysts  of  the  lips  or  cheeks,  varying  in  size  from  a  pea  to  a 
hazel  nut,  which  we  have  just  mentioned. 


TUMOURS    AND    ULCERS    IX    THE    MOUTH,    PHARYXX   AXD    XOSE         93 

It  has  been  shown  that  besides  the  ordinary  ranulae,  cysts  may 
arise  in  some  cases  from  Bochdalek's  ducts,  which  are  Hned  with 
cihated  epithehum,  Nuhn-Blandin's  glands  at  the  tip  of  the  tongue 
have  also  produced  cystic  structures,  but  these  have  nothing  in 
■common  with  ranulae,  because  they  are  situated  at  the  tip  of  the 
tongue  and  not  under  it. 

If  careful  attention  is  given  to  the  various  characteristics  of  ranulae 
it  is  difhcult  to  mistake  them.  Lxniphanglomaia,  which  have  been 
observed  in  this  vicinity,  are  much  less  sharply  defined,  and  they 
frequently  involve  the  tongue  itself.  They  are  composed  of  numer- 
ous small  vesicles  and  do  not  constitute  a  single-spaced  structure. 
Lipouiata   are   lobular   and    appear    yellowish,    as   seen    through   the 


Fig.  52. — Lipoma  of  floor  of  moiilh. 


Fig.  53.  —  Sub-lingual  dermoid. 


mucous  membrane.  Only  a  dermoid  could  lead  to  error  of  diagnosis 
because  it  is  also  a  single-spaced  structure.  Dermoids  which  occur 
in  this  region  nearly  as  frequently  as  ranul^e,  are,  however,  centrally 
situated,  whereas  ranulae  are  rather  laterally  placed  (ng.  53).  Their 
walls  are  thicker  than  those  of  ranulae,  and  the  cysts  present  rather  a 
whitish-yellow  than  a  bluish  appearance  from  beneath  the  mucous 
membrane.  Sometimes  they  are  closely  adherent  to  adjacent  tissues, 
or  are  even  attached  to  the  bone,  which  is  never  the  case  with  ranulae. 
They  are  also  more  liable  to  suppurate  than  the  latter. 

If  doubt  arises,  because  a   tumour  apparentlv  in   the  median  line 


94 


SURGICAL    DISEASES    OF   THE    HEAD 


gleams  through  the  mucous  membrane  with  a  bhush  tint,  e.g.,  a  large 
ranula  which  has  encroached  on  the  middle  line,  or  because  a  laterallv 
situated  cvst — dermoids  are  in  rare  cases  lateral — looks  like  a  dermoid^ 
the  diagnosis  can  be  cleared  up  by  a  puncture,  which  is  quite  harmless. 
The  treatment  is  similar  m  both  conditions,  so  that  an  error  in 
diagnosis  has  no  serious  consequences. 


(3)   THE    GUMS. 

A  tumour  projecting  from  the  margin  of  the  gum,  varying  in  size 
from  a  pea  to  a  walnut,   may  be  summarily  diagnosed  as  an   epulis, 


I.e., 


tumour  of    the    gum.' 


This    is,    of    course,  no    histological 


Fig.  54. — Epulis  growing  from  a  space  between 
teeih. 


Fig.  55. — Epulis  (pure  fibroma), 
with  impressions  of  upper  molars. 


diagnosis,  it  is  merely  a  description  of  what  is  found.  If  the  tumour 
is  of  the  same  colour  as  the  healthv  gum,  and  is  firm,  it  may  be 
regarded  as  a  pure  fibroiiia  :  if,  with  the  same  colour,  it  is  softer,  we 
must  conclude  that  it  is  richer  in  cells  and  blood  vessels,  and  there- 
fore approximates  to  a  sarcouia.  If  the  growth  is  darker,  with  a  faint 
shade  of  brown,  the  case  is  one  of  giant-celled  snrcouui,  springing 
from  the  alveolar  periosteum,  the  typical  form  of  epulis. 

These  growths  have  an  abundance  of  vessels  on  the  suiface  almost 
like  an  angioma,  all  the  rest  of  the  tumour  showing  the  structure  or 
a  giant-celled  sai  coma.      Thev  frequentlv  contain  a  brown  pigment 


TUMOURS    AND    ULCERS    IX    THE    MOUTH,    PHARYNX    AXD    XOSE        95 


in   addition.     Their  malignancy   is  limited  to   local    occurrence  ;    the 
glands  are  not  atiected  nor  do  metastases  occur. 

It  is  noteworthy  that  an  epulis  will  often  grow  from  a  site  which 
has  been  exposed  to  persistent  irritation,  e.g.,  in  the  spaces  between 
teeth,  in  the  neighbourliood  of  old  stumps  (fig.  54).  Occasionally  the 
epulis  becomes  somewhat  ulcerated  from  friction  on  its  surface,  and 
it  may  even  show  the  impression  of  the  opposite  teeth  (fig.  55). 

They  can  be  promptly  distinguished  from  tumours  of  the  jaw 
proper  bv  the  narrow  peduncle  which  connects  them  with  their  site 
of  origin.  At  first  sight  they  seem  to  be  situated  on  a  broad  base, 
but  if  thev  are  well  elevated  it  is  astonishing  to  ^■:ee  how  slight  their 
attachment  really  is. 

Granulations,  which  occur 
so  frequentlv  in  connection 
with  remains  of  stumps,  and 
not  infrequently  in  pulp  cavi- 
ties, must  be  distinguished 
from  epulides  which  are  really 
<^enuine  tumours.  In  neglected 
teeth,  the  whole  row  of  miss- 
ing crowns  may  be  occupied 
bv  such  granulations. 

<4)  PALATE,  TONSILLAR 
REGION,  BASE  OF 
TONGUE. 

A  semi -globular  swelling 
which  has  recently  developed 
in  the  middle  of  the  hard  palate 
is  usually  a  ginnina  ;  but  if  it 
embraces  the  margin  of  the 
palatal  plate,  or  if  it  is  close 
to  a  diseased  tooth  or  an  old  stump,  it  is  a  dental  abscess  (fig.  56). 

If  the  growth  arises  from  the  soft  palate  or  the  tonsillar  region,  and 
is  definitelv  capsulated  with  the  mucous  membrane  movable  over  it, 
we  must  think  of  one  of  those  mixed  tumours  which  more  frequently 
(jccur  in  the  parotid  region.  If  the  tumour  has  a  wide  attachment  to 
the  tonsillar  region,  and  is  only  slightly  or  not  at  all  movable,  the  case 
is  certainlv  one  of  sarcoma,  and  we  must  not  wait  for  enlarged  glands 
to  confirm  the  malignancy.  A  striking  swelling  of  the  whole  of  the 
Ivmphatic  system  of  the  pharynx  should  suggest  the  possibility  of 
leukaemia  or  pseudo-leukaemia. 

The  fact  that  many  tonsillar  sarcomata  have  vanished  after  energetic 
treatment  with  arsenic,  and  also  with  X-ravs,  has  not  only  a  therapeutic 


Fig.  56. — Abscess  of  palate  arising  from  root 
of  tooth. 


96  SURGICAL    DISEASES    OF   THE    HEAD 

but  also  a  diagnostic  interest.  These  tumours  must  be  classified  with 
the  still  somewhat  enigmatic  group  of  lymphosarcomata. 

Pedunculated  polypi  are  sometimes  found  on  the  palatine  arch^ 
especially  in  the  form  of — purely  innocent — papillomata. 

A  soft,  roundish  well-defined  tumour  at  the  base  of  the  tongue  is 
most  likely  to  be  an  aberrant  goitre. 

This  localization  is  explained  by  the  circumstance  that  the  central 
thyroid  gland  rudiment  grows  from  the  position  which  subsequently 
forms  the  base  of  the  tongue.  For  this  reason,  accessory  goitres  may 
be  met  w^ith  along  the  whole  remaining  track  of  this  rudiment, 
between  the  foramen  caecum  and  the  processus  pyramidalis  of  the 
thyroid  gland,  i.e.,  the  thyro-glossal  duct. 

Patients  with  lingual  goitre  feel  as  if  they  have  a  lump  in  the  throat,. 
which  cannot  get  down.  If  the  growth  is  extensive  the  speech  be- 
comes nasal,  and  ultimately  respiration  is  obstructed.  Sometimes 
severe  haemorrhage  occurs  from  the  superficial  vessels. 


(5)    PHARYNX. 

If  a  tumour-like  structure  projects  into  the  pharyngeal  cavity,  one 
must  endeavour  to  ascertain  its  point  of  origin,  by  means  of  the  eye, 
the  probe  and  the  finger.  If  it  has  a  broad  attachment  to  the  anterior 
surface  of  the  vertebral  column  it  might  be  a  sarcoma,  but  it  is  more 
likely  to  be  a  tubercular  abscess  due  to  spinal  caries.  The  stiff 
manner  in  which  the  patient  holds  his  head  will  already  have  suggested 
this  diagnosis  to  the  careful  observer ;  and  the  history  will  show  that 
the  tumour  in  the  pharynx  was  long  preceded  by  difficulty  in  moving 
the  head.  Palpation  will  also  show  at  once  whether  we  are  dealing 
with  an  abscess  or  a  solid  tumour. 

If  the  tumour  projects  into  the  pharynx  from  above,  it  may  be  an 
ordinary  mucous  polypus  arising  from  the  nose.  These  are  remark- 
ably soft  to  the  touch,  and  they  give  the  impression  of  receding  out 
of  the  way  of  the  palpating  finger.  If  they  are  visible,  directly  or 
through  the  mirror,  they  are  recognized  by  their  w^ll-known  bluish 
colour  and  their  glassy  translucent  appearance.  If  the  growth  is  of 
firmer  consistence  w^e  may  be  undecided  as  between  a  fibroma  spring- 
ing from  the  basilar  fibrocartilage  at  the  base  of  the  skull  in  young 
people,  and  a  sarcoma  proper  of  the  base.  As  the  dift'erential  diagnosis 
between  these  two  is  of  extreme  importance  for  prognosis  and  treat- 
ment, we  must  dwell  upon  it  for  a  moment. 

A  fibroma  of  the  base  of  the  skull,  usually  a  nasopharyngeal 
fibroma  or  a  nasopharyngeal  polypus,  can  be  excluded  if  the  growth 
has  occurred  after  the  termination  of  adolescence,  i.e.,  after  the  second 
decade.      Naso-pharyngeal    fibromata   have   the     peculiarity   of   only 


TUMOURS  AND  ULCERS  IX  THE  MOUTH,  PHARYNX  AND  NOSE   97 


developing  before  the  termination  of  this  period.  But  if  the  patient 
has  not  yet  completed  adolescence  the  growth  might  be  of  either 
variety.  In  doubtful  cases,  the  sex  as  well  as  the  age  is  of  assistance, 
because  in  infancy  nasopharyngeal  fibromata  are  of  equal  incidence 
in  both  sexes,  whereas  at  puberty,  when  they  are  most  frequent,  they 
only  attack  males.  The  previous  history  is  also  of  great  importance. 
If  the  growth  has  taken  years  to  develop  and  has  manifested  itself  by 
nasal  obstruction  and  occasional  severe  haemorrhages,  we  can  definitely 
exclude  sarcoma.  On  the  other  hand,  if  the  existence  of  the  growth, 
the  blocking  up  of  the  posterior  nares,  and  possibly  also  haemorrhages 
have  all  taken  place  within  a  few  months,  we  must  regard  the  case  as 
one  of  sarcoma.  If  the  new  growth  emits  processes  into  all  the 
accessible  cavities  in  the  neighbourhood,  processes  which,  if  visible, 
display  the  same  roundish  form,  and  the  same  sharp  definition  as 
the  tumour  within  the 
pharynx,  the  case  is  one 
of  fibroma.  On  the 
other  hand,  a  diffuse 
extension  of  the  tumour, 
the  early  onset  of  neu- 
ralgic pains  and  brain 
symptoms  are  in  favour 
of  sarcoma. 

Teratoid  growths 
of  various  kinds  are  to 
be  found  at  the  junction 
of  the  pharynx  and 
oesophagus  as  well  as 
in  other  positions  in  the 
pharynx.  They  may 
be  teratomata  proper 
formed    from     all     the 

three  layers  of  the  embryo,  with  a  tuft  of  hair  on  the  surface,  or  they 
maybe  simple  I  ipoinata  or  soit  fibromata  ;  the  latter  may  at  times  hang 
out  of  the  mouth  like  a  sausage  (see  fig.  57).  At  other  times  they  only 
appear  after  some  definite  cause,  such  as  vomiting,  and  then  are  again 
swallowed  by  the  patient. 


Fig.  57. — Pharyngeal  polypus,  with  a  long  pedicle 
arising  from  ihe  palatopharyngeal  arch. 


(6)  THE    NASAL   CAVITY. 

Non-ulcerating  new  growths  in  this  region,  as  in  the  pharynx, 
may  be  mucous  polypi,  fibrous  nasopharyngeal  polypi,  or  sar- 
comata. We  have  already  discussed  the  first  two,  and  would  only 
add  here  there  is  usually  some  accessory  sinus  catarrh  behind  the 
mucous  polypi.     But  for  the  formation  of  these  polypi  there  is  also 


98 


SURGICAL   DISEASES   OF   THE    HEAD 


required  a  special,  and  often  a  very  obstinate  predisposition,  which 
tends  to  the  constant  development  of  new  polypi.  In  fact,  the  shape 
of  the  nose  may  be  so  greatly  deformed  in  some  cases  in  the  course 
of  a  few  years,  that  a  fibrous  polypus  or  even  a  sarcoma  would  be 
diagnosed,  if  the  previous  history  were  unknown.  Sometimes  the 
appearance  of  a  bluish  mucous  polypus  at  the  nostril  leads  im- 
mediately to  a  correct  diagnosis. 

Sarcomata  of  the  nose  usually  start  from  the  turbinated  bones, 

and  in  the  beginning 
are  merely  regarded  as 
hypertrophied  mem- 
brane. When  they  take 
on  rapid  growth,  cause 
nasal  obstruction 
and  hjemorrhage,  a 
small  portion  excised 
for  histological  exami- 
nation will  make  the 
diagnosis  positive,  or 
confirm  it  if  already 
made. 

5.— ULCERATION 
PROCESSES. 

Two  points  must  be 
impressed  upon  the 
beginner  in  regard  to 
the  diagnosis  of  ulcers, 
viz.,  to  closely  examine 
the  characteristics  of 
the  margin  of  the 
ulcer,  and  to  investi- 
gate its  base.  This  rule 
also  applies  to  ulcers 
of  the  oral  cavity,  but 
it  encounters  many 
difficulties  in  this 
region  owing  to  ana- 
tomical conditions  and 
the  occasional  inaccessibility  of  the  tumour.  However,  a  superficial 
ulcer  with  a  soft  border  and  a  soft  greyish  base  is  tubercle;  an  ulcer 
w^ith  a  fatty,  yellowish  base  is  a  giiuiuia ;  a  hard  undermined  border 
with  a  hard  segmented  base,  often  covered  with  necrotic  shreds,  points 
to  cancer;  and  an  ulcer  of  firm  consistence  without  undermined 
edges,  but  with  a  smooth,  varnished-looking  base  suggests  a  primary 
chancre.     But  one  must  not  conclude  from  this  that  a  cancer  must 


Fig.  58. — Mucous  polypus  of  the  nose. 

This  figure  represents  a  patient  who  regularly  for  fifteen 
years  was  relieved  from  time  to  time  of  whole  bunches  of 
mucous  polypi  from  both  nasal  passages,  before  she  made 
up  her  mind  to  undergo  operative  treatment  for  her 
bilateral  accessory  sinus  catarrh. 


TUMOURS   AND    ULCERS   IN   THE   MOUTH,    PHARYNX   AND   NOSE         99 

always  have  undermined  edges  and  be  segmented,  and  that  a  gumma 
necessarily  must  have  a  yellowish,  fatty  base  in  all  its  stages. 

Our  diagnosis  will  always  be  most  accurate  when  we  bear  in  mind 
the  most  frequent  morbid  conditions  which  occur  in  the  various 
portions  of  the  oral  cavity. 


(1)  THE  MUCOUS  MEMBRANE  OF  THE  LIPS  AND 

CHEEKS. 

Cancer  is  the  most  frequent  lesion  in  this  part,  although  tubercle, 
gumma,    and  primary  chancre    are    possibilities.      We    have   already 
discussed   cancer    of   the  lip.     Cancer  of  the  mucous  membrane  of 
the    lip    is    much    rarer,    but  its 
prognosis  is  much  worse.  F 

The     following    case    shows       \ 
liow  difficult  the  diagnosis  may 
be,   on  the    assumption    that  an 
ulcer  of  the  lip,"  in  an  old  man, 
must  be  cancerous. 

A  man,  over  70,  an  old  sufferer  I 
from  bronchitis,  had  an  ulcer  on 
his  left  lower  lip,  and  another  one 
on  the  mucous  membrane  of 
his  right  cheek.  They  were  both 
soft,  superficial  and  very  pain- 
ful. There  were  neither  epithelial 
plugs  nor  tubercles  visible.  The 
history  of  syphilis  was  very  in- 
definite, and  the  pain  contra- 
indicated  it.  The  only  point  in 
favour  of  cancer  was  the  age, 
everything  else  was  against  it, 
and  the  pain  suggested  tubercle. 
The  bronchitis  appeared  to  be  '" 
ordinary  senile  bronchitis.  The 
diagnosis  of  tubercle  could  only 
only  be  made  by  a  process  of 
exclusion,  but  its  accuracy  was  established  by  histological  examination 
of  a  piece  of  the  border  excised  for  the  purpose. 

It  is  hardly  necessary  to  mention  the  small  transitory  ulcers  on 
the  mucous  membrane  of  the  cheek,  which  are  so  often  produced 
by  bites. 

(2)  THE    FLOOR    OF   THE    MOUTH. 

Carcinoma  is  of  frequent  occurrence  on  the  floor  of  the  mouth  ; 
tubercle  and  primary  chancre  are  rare.  In  its  early  stages  the  cancer 
appears  as  a  small,  movable,  roundish,  definitely  raised  tumour, 
presenting  as   its   centre  a  small   superficial  ulcer  surrounded   by  an 


Fig.  59. — Sub-lingual  cancer. 
Tongue  drawn  aside. 


lOO  SURGICAL   DISEASES   OF   THE    HEAD 

encroaching  border.  This  in  itseh'  suffices  to  justify  the  diagnosis. 
The  practised  observer  will  involuntarily  feel  for  enlarged  hard  glands 
after  examining  the  growth  in  question,  in  order  to  confirm  the  diag- 
nosis. The  presence  or  absence  of  glands  must,  however,  not  be 
invested  with  too  great  a  significance,  at  any  rate  their  absence  is  not 
a  conclusive  argument  against  cancer.  If  the  tumour  has  become 
adherent  to  the  jaw  and  eventually  also  to  the  tongue,  so  that  the 
latter  gets  fixed  and  movements  of  mastication  and  speech  are  inter- 
fered with,  the  diagnosis  is  easy  enough. 


(3)  THE    GUMS. 

The  careful  examination  of  the  gums  is  not  only  of  importance 
to  the  dentist  and  the  physician,  but  also  to  the  surgeon.  For  in- 
stance, a  persistent  colic,  which  might  be  attributed  to  organic 
obstruction  of  the  bowel,  will  be  shown  to  be  toxic  in  origin,  by  the 
discovery  of  the  well-known  blue  line  on  the  gums. 

In  a  case  of  obstinate  suppuration  between  a  tooth  and  the  gum, 
and  general  loosening  of  the  teeth,  we  should  not  treat  the  gum,  but 
should  examine  the  urine  for  sugar.  If  this  examination  does  not 
reveal  the  cause  of  the  alveolar  pyorrhcva,  some  other  general  disease 
should  be  searched  for. 

If  called  to  arrest  obstinate  haemorrhage  from  a  tooth,  we  must 
not  be  content  with  apphang  a  styptic,  but  must  investigate  the  cause 
of  the  bleeding,  which  may  be  due  to  a  hitherto  overlooked  Jweuio- 
pliilia,  to  a  leulicvuiia,  or  to  chronic  jaundice. 

Alost  clirouic  iuliauiuiatorv  diseases  of  the  gums  depend  upon 
dental  disease.  If  thev  do  not  recover  after  extraction  of  the  bad 
teeth,  the  removal  of  stumps  or  sequestra,  we  should  suspect  actino- 
mycosis, tubercle,  or  phosphorus  necrosis.  We  have  already  discussed 
the  diagnosis  of  these  conditions. 

Ulcers  which  are  surrounded  by  a  definitely  inflamed  area  must 
be  diagnosed  in  the  same  way  as  those  on  any  other  part  of  the 
oral  mucous  membrane.  It  will  be  necessary  to  differentiate  between 
cancer,  tubercle,  3.nd  gnniuia.  Primary  cliancre  is  very  rare.  The  lead- 
ing points  of  differential  diagnosis  have  already  been  adequately  stated. 

Finally,  swellings  which  bleed  easily  are  due  to  scurvy,  and  in 
little  children  indicate  Barlow's  disease. 

It  is  noteworthv  that  in  the  latter  condition  the  unmistakable 
bluish-red  swelling  of  the  gum  only  occurs  where  teeth  have  already 
erupted.  The  pain  in  the  extremities  completes  the  clinical  picture 
and  demands  that  we  should  not  incise  the  swelling  in  the  gum^ 
but  should  adopt  immediately  the  only  prompt  and  effective  treatment, 
i.e.,  the  abandonment  of  all  artificial  or  artificial^  sterilized  food. 


TUMOURS  AXD  ULCERS  IN  THE  MOUTH,  PHARYNX  AND  NOSE   TO! 

(4)  THE    TONSILLAR    REGION. 

Various  forms  of  ulcer,  cancer,  primary  chancre,  tubercle  and 
gumma  have  to  be  considered  here,  as  well  as  the  somewhat  rare 
non-specific  ulcer  of  the  tonsil.  The  first  lead  in  diagnosis  is  given 
by  the  presence  or  absence  of  glandiihir  ciilargcnwnt. 

{a)  If  the  glands  are  not  enlarged  we  mav  exclude  chancre,  unless 
it  be  quite  recent;  and  we  should  think  of  cancer  and  gumma,  possibly 
also  of  tubercle. 

The  frequency  of  carcinoma  renders  its  presence  more  likely  than 
that  of  any  other  ulcer.  If  the  patient  is  an  alcoholic,  this  supports 
the  diagnosis,  because,  in  mv  experience,  tonsillar  cancer,  and 
especially  cancer  of  the  pharynx,  have  mainly  occurred  among  heavy 
drinkers.  The  fact  that  only  one  ulcer  is  present  is  also  in  favour 
of  cancer,  apart  from  its  hard  base  and  border.  Gummatous  and 
tubercular  ulcers  are,  on  the  other  hand,  frequentlv  multiple.  Pains 
radiating  towards  the  ear  and  robbing  the  patient  of  sleep  at  once 
dispose  of  gumma  and  tubercle.  Pain  limited  to  swallowing  is 
strong  presumption  against  a  gumma,  but  not  against  tubercle.  The 
absence  of  pain  is,  however,  no  evidence  against  cancer,  because 
pain  may  not  come  on  until  a  stage  wherein  operative  measures  are 
useless. 

If  the  consistence  and,  perhaps,  the  multiplicitv  of  the  ulcers  show 
that  it  is  either  tubercle  or  gumma,  the  presence  of  separate  little 
nodules  on  a  reddened  base  around  the  ulcer  points  to  tubercle, 
whereas  the  partial  aggregation  of  areas  which  start  as  roundish 
nodules  and  their  subsequent  disintegration  in  the  centre,  point  to 
gumma.  These  characteristics  are  sometimes  difficult  to  detect,  and 
it  is  therefore  all  the  more  important  to  pa}^  attention  to  the  history 
of  the  patient  and  his  general  condition.  There  is  generally  some 
preceding  pulmonary  or  intestinal  tuberculosis  in  cases  of  pharyngeal 
tubercle,  and  although  the  most  carefully  taken  history  will  not  always 
reveal  svphilis  in  cases  of  gummata,  it  very  frequentlv  will  do  so. 
In  doubtful  cases,  we  must  resort  to  histological  and  bacteriological 
investigation,  lest  we  overlook  cancer. 

A  small  piece  of  the  edge  of  the  ulcer  should  be  snipped  off  with 
forceps,  or  scissors,  and  a  part  thereof  submitted  for  histological 
examination  and  a  part  used  for  animal  inoculation.  The  micro- 
scope will  settle  the  diagnosis  with  certainty  in  a  few  hours  or  within 
a  day  or  two  ;  guinea-pig  inoculations  take  at  least  four  to  six  weeks  ta 
supply  definite  information.  Quite  recently  some  experienced  observers 
have  cast  doubt  on  the  value  of  this  kind  of  histological  examina- 
tion. Personally  I  have  emploved  this  method  for  many  years  in 
my  own  practice,  and  have  had  very  reliable  results  when  the  little 
pieces  are  taken   from  the  right  place  and   the  sections  are  cut  in  a 


102  SURGICAL    DISEASES    OF    THE    HEAD 

proper  direction.  It  would  be  best  it  the  person  who  lias  excised 
the  specimen  would  himself  examine  it,  but  as  this  is  usually  im- 
practicable, he  should  inform  the  pathologist  of  the  exact  disposition 
of  the  piece  submitted,  so  that  sections  should  be  cut  perpendicularly 
to  the  margin  of  the  ulcer.  It  would  be  useful  to  examine  a  piece 
from  the  margin  and  a  piece  from  the  base  of  the  ulcer  at  the  same 
time.  If  this  investigation  is  negative  and  clinical  signs  are  suspicious, 
we  must  not  be  content  until  another  and  larger  piece  has  been 
removed,  if  it  is  impossible  to  establish  the  diagnosis  in  anv  other 
wav. 

The  result  of  a  Wassermann  test  should  always  be  taken  into 
consideration,  but  it  must  not  be  forgotten  that  a  syphilitic  may 
become  affected  with  tubercle  or  cancer.  Diagnosis  "ex  juvantibus  " 
still  holds  the  field  in  syphilis. 

(6)  Diagnosis  is  facilitated  if  enlarged  glands  arc  present.  If  they 
have  come  on  soon  alter  the  appearance  of  the  ulcer,  and  have 
reached  a  fair  size  in  a  short  time,  and  are  adherent  to  the  adjacent 
tissues,  we  mav  assume  that  the  glands  are  in  a  state  of  early  fibrosis. 
The  minutest  superticial  injuries  suffice  for  infective  material  derived 
from  dirty  drinking  vessels  to  stick  to  the  tonsils. 

One  illustration,  out  of  man}',  may  be  given.  A  student  drank  out 
of  a  drinking  horn  directly  after  an  old  man,  in  token  of  mutual 
lovalty.  The  student  acquired  a  tonsillar  chancre,  and  it  subsequently 
transpired  that  the  old  man  had  signs  of  secondary  syphilis  in  his 
mouth — an  instance,  bv  the  way,  of  the  neglect  of  elementary  rules 
of  hygiene,  prevalent  at  the  present  day. 

If  the  glands  have  not  enlarged  until  some  considerable  time  has 
elapsed  since  the  appearance  of  the  ulcer,  then  the  diagnosis  lies 
between  carcinoma  and  tubercle.  In  the  former  case  thev  are  hard, 
in  the  latter  rather  softer.  In  both  cases  thev  may  become  adherent, 
so  that  no  conclusion  can  be  drawn  from  this  condition  ;  but  enlarged 
glands  which  have  existed  for  many  months  without  contracting 
adhesions  around  are  more  likely  to  be  tubercular  than  cancerous. 
The  adhesions  of  cancerous  glands  are  of  a  very  firm  kind,  so  that 
hai"d  immovable  masses  are  formed.  After  tubercular  glands  have 
contracted  adhesions,  suppuration  generally  takes  place  in  the  centre, 
so  that  it  will  be  found  that  soft,  elastic,  and  even  fluctuating  areas 
■exist,  surrounded  by  comparatively  hard  borders. 

Xo  conclusions  can  be  drawn  from  the  condition  of  the  ulcer,  or 
of  the  glands  existing  at  the  time,  if  the  attention  of  the  patient  or  the 
medical  attendant  has  first  been  directed  to  the  presence  of  an  ulcer 
bv  the  onset  of  glandular  enlargement. 

It  may  be  stated  finally  that  Plaut-Vincent's  angina  {see  infra)  in  the 
ulcerative  stage  may  easily  be  mistaken  for  a  syphilitic  ulcer.  The 
bacteriological  findings  and  the  rapid  recovery  are  decisive. 


TUMOUKS  AND  ULCERS  IX  THE  MOUTH,  PHARYNX  AND  NOSE   lOJ, 

(5)  HARD  AND  SOFT  PALATE. 

A  solitary  ulcer  spreading  from  the  tonsillar  region  towards  the 
margin  of  the  soft  palate  is  usually  a  carcinoma.  Carcinoma  rarely 
begins  on  the  soft  palate,  but  we  have  seen  it  entirely  eaten  away  by 
a  primary  cancer.  A  swelling  in  this  region  is  much  more  likely  to  be 
a  gumma,  especially  if  it,  or  the  ulcers,  are  near  the  linrd  palate,  or 
actually  on  it,  or  if  they  have  already  perforated  it. 

Tubercle  also  occurs  on  the  soft  palate.  It  differs  from  gumma 
in  its  longer  duration,  in  the  appearance  of  the  ulcer,  and  also  by 
causing  severe  dysphagia,  and  by  rarely  failing  to  produce  glandular 
enlargement. 

(6)   PHARYNGEAL  WALL. 

Ulcers  on  the  mucous  membrane  of  the  pharynx  are  of  rare 
occurrence,  apart  from  those  at  the  base  of  the  tongue  and  the 
tonsillar  region.  Cancers  are  usually  found  at  the  entrance  to  the 
gullet,  in  the  neighbourhood  of  the  roof  of  the  pharynx  and  in 
the  vicinity  of  the  posterior  nares.  As  they  arise  in  such  concealed 
situations,  enlargement  of  the  glands  is  usually  their  first  indication, 
and  they  require  a  careful  rhinoscopic  examination.  Ulcers  on 
the  posterior  wall  of  the  pharynx  are  usually  gummata.  It  is  also 
necessary  to  mention  the  bedsore  caused  by  the  cricoid  cartilage  in 
very  chronic  diseases. 

(7)  NASAL   CAVITY. 

We  leave  the  round  ulcer  of  the  septum  to  the  rhinologist,  so  that 
cancer,  svphilis  and  tubercle  again  come  under  consideration.  A 
careful  examination  with  a  mirror  is  generally  indispensable,  but  there 
are  certain  concomitant  conditions  of  the  diseases  which  are  useful  for 
differentiating  one  from  the  other. 

There  are  certain  tumours  and  ulcers  of  the  pharynx  and  nose, 
which  would  only  be  diagnosed  if  we  are  aware  of  the  patient's  occu- 
pation, or  of  his  geographical  relationships.  These  include  the  ulcers 
of  glanders  in  the  nose  of  people  who  attend  to  horses  suffering  from 
farcy,  leprosy,  and  rhinoscleroma  of  certain  districts,  the  latter 
usually  from  the  Balkans.  The  diagnosis  of  leprosy  will  be  made 
from  the  other  appearances  of  the  disease,  and  rhinoscleroma  will  be 
recognized  by  the  "hardness  of  the  infiltration,  the  absence  of  glandular 
enlargement,  and  the  chronic  course  of  the  disease. 

A  young  man  returned  home  from  a  sanatorium  with  his  pul- 
monary condition  improved,  but  he  had  an  ulcer  in  the  nose  which 
gradually  ate  away  the  septum.  In  such  a  case,  nothing  hui  tnherde 
would  be  thought  of. 

An    aged  grandmother   complained  of  ''  a  cold  in   the   head,"  or,. 


I04  SURGICAL   DISEASES   OF   THE    HEAD 

rather,  of  a  persistent  and  profuse  nasal  discharge.  She  produced  a 
few  shreds  of  bone,  which,  to  her  amazement,  had  escaped  with  the 
■discharge.  Her  previous  history  told  of  one  living  child  after  a  series 
■of  miscarriages.  Iodide  of  potassium  worked  wonders.  We  shared 
her  pleasure  at  this  result,  but  we  were  careful  not  to  tell  her  that  this 
was  a  reminder  of  her  late  husband,  whose  portrait  discreetly  smiled 
on  us  from  the  wall. 

A  middle-aged  patient  came  with  a  bloody,  offensive  discharge  from 
one  nostril,  which  had  lasted  for  some  months.  There  had  been  hard 
glands  at  the  angle  of  the  jaw  for  the  last  few  weeks.  This  could  be 
nothing  but  cancer. 


CHAPTER   XIX. 
CHRONIC  DISEASES  OF  THE  TONGUE. 

The  custom  of  the  old  physicians — who  invariably  looked  at  the 
patient's  tongue — was  no  idle  habit,  and  the  younger  generation 
neglect  this  diagnostic  aid  too  much,  in  favour  of  "exact"  methods  of 
diagnosis.  The  surgeon  should  find  interest  not  onlv  in  the  colour  of, 
and  the  deposit  on,  the  tongue,  but  particularly  in  its  degree  of 
moisture.  Nothing  affords  us  a  more  rapid  conception  of  the  patient's 
condition  and  of  the  prognosis  in  infective  diseases,  like  peritonitis, 
than  a  glance  at  the  tongue.  A  dry  tongue  of  normal  colour  is  worse 
than  a  moist  tongue,  however  much  coated  it  may  be. 

We  will  not  refer  to  the  various  superficial  changes,  such  as  the 
map-like  tongue,  the  black,  hairy  tongue,  the  wrinkled  tongue,  &c., 
because  they  possess  no  surgical  significance  ;  but  leukoplakia  must 
he  noted,  because  it  forms  an  excellent  soil  for  the  development  of 
cancer.  It  is  now  generally  recognized  that  the  abuse  of  tobacco  and 
syphilis  are  equally  responsible  for  this  latter  condition. 

Fournier  has  asserted  that  in  Paris  cancer  of  the  tongue  is,  so  to 
say,  a  sequela  of  syphilis,  with  leukoplakia  as  an  intermediate  stage. 
This  statement  can  only  be  applied  to  other  countries  with  con- 
siderable reserve. 

As  in  the  preceding  chapter,  we  must  separate  here  also  the 
ulcerated  from  the  non-ulcerated  changes. 

(i)  NOX-ULCERATED  TUAIOURS  AND  SWELLINGS. 

We  must  first  refer  to  macroglossia  among  the  new  growths  of  the 
tongue.     It  is  a  diffuse  enlargement  of  the  whole  organ,  which  does 


CHRONIC   DISEASES   OF   THE   TONGUE  I05 

not  concern  so  much  the  muscular  structure,  but  consists  of  an 
increase  of  interstitial  tissue  and  lymph  spaces,  so  that  it  might,  with 
more  or  less  accuracy,  be  called  a  dijfusc  lyuipJiangiouia.  The 
muscular  structures  take  comparatively  little  part  in  macroglossia. 
When  this  condition  is  fully  developed  it  imparts  an  imbecile 
expression  to  the  face,  but  we  must  not  therefore  conclude  that  all 
who  are  affected  therewith  are  idiots.  Nevertheless,  macroglossia 
does  occur  most  frequently  among  those  whose  mental  development 
is  defective.  One  of  the  signs  of  hypo-  and  athyroidism  is  a  certain 
degree  of  diffuse  enlargement  of  the  tongue,  which  gradually  decreases 
in  size  under  the  influence  of  specific  treatment. 

Among  the  iriic  tinnours  of  the  tongue  cavernous  angioma  is  at 
once  recognized  by  its  colour  and  by  easily  emptying  on  pressure. 
Circumscribed  lymphangiomata  are  not  so  easily  diagnosed.  They 
appear  as  fairly  firm  nodules  in  the  soft  tissue  of  the  tongue,  usually 
on  the  dorsum  (tig.  60),  but  sometimes  also  on  its  under  surface 
(fig.  61).  As  with  other  lymphangiomata  their  contents  cannot  be 
well  expressed.  Were  it  not  for  the  long  duration  of  the  disease,  one 
might  be  tempted  to  think  of  some  chronic  infiammatory  process,  of 
a  tubercular  nodule,  or  of  actinomycosis.  But  if  we  carefully  examine 
the  tongue  we  shall  note  that  the  papillae  around  the  tumour  are 
prominent  and  enlarged  and  that  some  of  them  form  little  vesicles. 
This  is  decisive  for  the  diagnosis  of  lymphangioma. 

If  we  feel  soft  lobulated  growth  within  the  substance  of  the  tongue 
we  may  claim  it  as  a  lipoma,  and  thus  add  one  more  to  the  dozen 
cases  which  have  hitherto  been  recorded. 

But  much  more  important  than  the  recognition  of  such  rarities, 
is  the  accurate  diagnosis  of  tubercle,  guniiiia,  actinomycosis,  sarcoma 
and  cancer. 

We  mention  cancer  last,  and  then  only  with  considerable  reserve, 
because  it  never  occurs  in  the  tongue  with  an  undamaged  mucous 
membrane.  Glandular  cancer,  which  alone  can  come  into  considera- 
tion, is  so  rare  that  it  is  hardly  necessary  to  reckon  with  it.  But,  on 
the  other  hand,  inexperienced  observers  are  liable  to  declare  that  a 
cancer  is  not  ulcerated  when  they  have  failed  to  see  it  properly.  Care- 
ful observation  will  often  reveal  a  deep  ulceration  below  the  raised 
mass  of  new  grow^th  which  may  be  covered  by  normal  mucous 
membrane,  and  close  inspection  \vill  often  show  that  a  nodule  which 
can  be  easily  seen  and  is  apparently  non-ulcerated,  is  covered  by 
epithelium  which  even  macroscopically  is  abnormal. 

A  pednncnlated  nodnle,  soft  as  the  tongue  itself  and  situated  thereon, 
must  be  regarded  as  a  fibroma.  It  is  rare,  but  occurs  on  the  tongue, 
as  it  does  on  other  parts  of  the  oral  mucous  membrane.  Its  long 
duration  \\\\\  serve  to  prevent  its  confusion  with  sarcoma.  A  nodule 
which  has  arisen  within  a  few  months  and  is  iirmer  than  the  tongue 


io6 


SURGICAL    DISEASES    OF    THE    HEAD 


substance  must,  however,  be  looked  upon  as  a  sarcoma.  There  are 
also  soft  sarcomata  ;  but  they  do  not  possess  the  toughness  of  soft 
fibromata  ;  thev  soon  break  down  and  form  deep  ulcers. 

If  the  nodule  is  iufiltraicd  within  the  tissue  of  the  tongue  we  must 
differentiate  between  tubercle,  guuuna,  actiiwuixcosis  and  siircoina. 

It  must  be  regarded  as  a  sarcoma  if  its  size  is  greater  than  is  com- 
patible with  an  inflammatory  granulation  tumour.  A  lump  as  large 
as  a  hen's  egg  will  be  neither  a  tubercle  nor  a  gumma.  In  the  case 
of  smaller  tumours  the  early  onset  of  radiating  pains  points  to  malig- 
nancy. But,  as  a  rule,  we  should  only  diagnose  sarcoma  of  the 
tongue  when  there  is  no  more  plausible  possibility,  because  it  is  a 
condition   of  great  rarity. 


Fig.  6o. — Lymphangioma  of  the  tongue. 


Fig.  6i. 


-Cystic  lymphangioma  of  the 
tongue. 


The  local  circumstances  often  suffice  to  differentiate  between 
gumma  and  tubercle.  A  nodule  of  a  few  weeks  standing  which  has 
not  yet  broken  down,  is  more  likely  to  be  tubercle  than  gumma. 
Other  things  being  equal,  the  fact  that  a  tumour  is  single,  is  in  favour 
of  tubercle.  Tubercular  nodules  are  also  more  painful  than  gummata; 
the  latter  may  be  sensitive  on  pressure  but  are  only  very  slightly  pain- 
ful in  themselves.  Soft  swelling  of  the  glands  of  the  neck  points  to 
tubercle,  as  already  stated  in  connection  with  ulcers  of  the  pharynx. 
Gummata  are  not  associated  with  glandular  enlargement,  if  they  are 
unbroken  and  therefore  not  secondarilv  infected.  The  previous 
history  and  general   condition  of  the  patient  are  also  of  importance^ 


CHRONIC    DISEASES    OF   THE    TOXGUE  IO7 

Experience  shows  that  tubercle  of  the  tongue  is  very  rarely  a  primary 
manifestation  ;  as  a  rule,  it  occurs  only  in  patients  who  are  suffering 
from  pulmonary  or  abdominal  tuberculosis.  Similarly,  in  cases  of 
gumma,  the  history  or  the  general  condition  of  the  patient  will  provide 
evidence  of  old  syphilis.  Finally,  as  in  all  these  cases,  we  have  the 
serum  reaction  and  the  therapeutic  test  as  ultimate  resources. 

A  deep-seated  nodule  of  actinouixcosis,  which  occasionally  occurs  in 
the  tongue,  is  distinguished  from  gumma  by  its  hardness,  and  from 
tubercle  by  the  absence  of  the  characteristic  glandular  enlargement. 
If  the  disease  has  involved  the  surface,  it  consists  of  a  board-like  in- 
filtration of  the  tongue  permeated  by  soft  foci  of  granulation  tissue, 
so  distinctive  of  actinomycosis  elsewhere.  It  is,  therefore,  only  in 
the  early  stage  that  it  presents  any  diagnostic  difBculties  in  the  tongue. 
If  it  has  broken  down,  it  is  important  to  examine  the  pus  repeatedly 
for  the  detection  of  the  well-known  granules. 

(2)   ULCERATIVE    DISEASES    OF   THE    TOXGUE. 

In  coming  to  any  conclusion  about  an  ulcer,  it  must  not  be  for- 
gotten that  all  lesions  within  the  oral  cavity  tend  to  ulcerate,  especially 
as  a  consequence  of  friction  against  the  teeth.  The  mucous  membrane 
over  a  sarcoma  may  therefore  become  destroyed  from  secondary 
causes.  But  in  such  a  case  the  growth  itself  is  usually  so  prominent 
that  the  true  state  of  affairs  is  perfectly  evident.  Advanced  sarcomata, 
which  have  broken  down  extensively,  are  easily  mistaken  for  cancer, 
in  the  absence  of  a  microscopic  examination. 

The  reader  is  referred  to  the  discussion  on  ulcers  of  the  oral  cavity, 
for  the  differentiation  between  tubercle,  primarv  sore,  giunuia  and 
cancer ;  but  a  few  special  points  may  be  mentioned  here. 

When  a  deep-lying  tubercular  focus  breaks  dowMi,  the  lesion  in 
the  mucous  membrane  does  not  always  assume  the  characters  of  a 
fully  developed  ulcer.  A  probe  only  penetrates  through  a  small  open- 
ing, more  like  a  fistula  than  an  ulcei",  into  a  wide  pocket  corresponding 
to  the  original  extent  of  the  diseased  focus.  But  when  a  gumma 
breaks  down  there  forms  immediately  an  extensive  lesion  of  the  con- 
nective tissue  and  mucous  membrane.  Gummata  differ  from  cancer 
in  being  situated  in  the  middle  of  the  dorsum  of  the  tongue  or  on  its 
tip.  Cancer  nearly  always  starts  on  the  edge  of  the  tongue  (fig.  62) 
and  gradually  invades  the  centre. 

Besides  the  well-defined  gummata  of  the  tongue  there  occurs 
occasionally  a  diffuse  guuiuiafous  infiltration  of  the  organ,  lout  this  is 
differentiated  from  cancer  by  its  indefinite  limitation  and  the  fact 
that  it  does  not  break  down. 

Finally,  it  should  be  noted  that  deep  and  often  painful  rliagades 
on  the  tongue  are  to  be  attributed  to  tertiary  syphilis,  although  there 
ma}^  be  no  definite  gummatous  changes  present. 


io8 


SURGICAL   DISEASES    OF   THE    HEAD 


As  far  as  the  diagnosis  of  cancer  is  concerned  the  warning  must 
again  be  given  that  it  is  neghgent  to  await  the  development  of  all 
possible  symptoms  and  finally  glandular  enlargement,  before  inform- 
ing the  patient  of  the  nature  and  gravity  of  his  disease.  It  is  especially 
wrong  to  comfort  him  with  the  assumption  that  he  is  suffering  from 
an  ulcer  caused  by  a  tooth,  until  it  becomes  too  late.  Often  enough  it 
does  happen  that  a  sharp  tooth  or  a  jagged  stump  injures  the  edge  of 
the  tongue,  causing  a  small  superficial  ulcer  which  fails  to  heal  be- 
cause it  is  subject  to  constant  friction.  But  the  removal  of  the 
offending  tooth  or  the  filing  of  the  sharp  points,  without  doing  any- 
thing at  all  to  the  ulcer,  will  result  in  its  healing  within  a  few  days. 

If  it  does  not  heal,  it  signifies 
that  the  case  is  somewhat  more 
serious,  and  careful  palpation 
will  no  doubt  reveal  distinct 
hardness  of  the  base  and 
margin.  To  wait  any  longer 
in  such  a  case,  in  order  not  to 
alarm  the  patient,  is  a  delicacy 
of  feeling  which  may  cost  the 
patient  his  life. 

But  cancer  does  not  always 
begin  in  this  manner.  Some- 
times it  starts  as  a  small  hard 
nodule,  with  no  loss  of  surface 
epithelium  visible  to  the  naked 
eye,  but  around  w^hich  slight 
contractures  of  the  tongue 
tissue  may  be  seen.  Such  a 
condition  renders  any  further 
observation  superfluous  ;  it 
demands  immediate  operation. 
In  other  cases  we  have  to  deal 
with  patients  who  have  been 
suffering  from  leukoplakia  for 
years.  Having  been  informed  that  this  disorder  predisposes  to  cancer 
they  bestow  the  necessary,  and  more  than  necessary,  notice  on  their 
oral  mucous  membrane,  and  obtain  medical  advice  as  soon  as  they 
discover  any  thickening  of  a  leukoplakia  patch.  Often  enough  such 
a  patient  is  obsessed  with  the  fear  of  carcinoma,  and  fancies  that 
there  is  some  hardening  present  when  in  reality  there  is  none.  The 
practitioner  must  not  be  too  ready  with  his  reassurance  ;  the  suspected 
spot  must  be  most  carefully  palpated  and  compared  with  the  other 
spots.     If  there  is  any  hardening  it  must  be  treated  as  cancer,  even. 


Fig.  62. — Cancer  at  the  edge  of  the  tongue. 


CHRONIC    DISEASES   OF   THE   TONGUE  109 

though  the  unaided  eye  detects  no  loss  of  epithehum.  At  any  rate 
the  patch  should  be  excised  and  submitted  to  microscopic  examina- 
tion, with  a  view  to  a  more  extensive  operation  if  the  diagnosis  is 
confirmed, 

Cancers  which  so  frequently -start  at  the  hinder  edge  of  the  tongue, 
opposite  the  tonsil,  escape  detection  for  a  considerable  time.  When 
they  are  discovered,  they  are  usually  so  far  advanced  that  it  is 
impossible  to  say  whether  they  have  started  from  the  tongue  and 
invaded  the  tonsil  or  vice  versa. 

It  is  usually  said  that  cancer  of  the  tongue  occurs  in  middle  and  in 
old  age,  and  only  in  the  male  sex.  But  such  a  generalization  should 
not  be  allowed  to  influence  us  too  much  in  arriving  at  a  decision.  This 
is  illustrated  by  the  following  case. 

A  girl  aged  22  consulted  a  doctor  about  an  ulcer  on  the  side 
of  the  tongue.  The  age  and  sex  were  such  strong  contra  indica- 
tions of  cancer  that  the  treatment  was  limited  for  a  long  time  to 
gargles  and  the  application  of  lunar  caustic.  Eventually,  the  doctor 
became  uncomfortable  at  the  constant  increase  of  the  ulcer.  Examin- 
ation then  showed  that  a  large  portion  of  the  left  border  of  the  tongue 
was  occupied  by  a  shallow  ulcer  with  slightly  projecting  but  somewhat 
undermined  edges.  The  border  and  the  base  were  hard,  but  only  to  a 
slight  depth.  There  were  a  few  hard  glands  in  the  neck.  There  were 
no  points  in  favour  of  tubercle  or  syphilis.  The  clinical  diagnosis  of 
cancer  was  confirmed  by  a  test  excision.  The  operation,  which  was 
very  extensive,  did  not  succeed  in  preventing  a  recurrence. 


PART   II. 
SURGICAL  DISEASES   OF  THE  NECK. 


CHAPTER   XX. 

SURGICAL    DISEASES    OF   THE    RESPIRATORY 
TRACT.     (LARYNX   AND   TRACHEA.) 

Diseases  of  the  larynx  have  become  so  separate  a  department  of 
practice  that  the  general  practitioner,  in  the  stress  of  his  daily  work, 
does  not  scruple  to  declare  himself  unequal  to  them,  at  any  rate  he 
consoles  himself  for  not  making  a  careful  examination  by  avowing 
that  he  is  not  a  specialist.  Although  it  is  true  that  the  diagnosis  of 
these  diseases  at  the  present  day  demands  complicated  methods  which 
are  often  out  of  the  reach  of  the  general  practitioner,  there  still  remain 
a  number  of  maladies  which  he  can  and  must  correctly  diagnose.  It 
may  then  be  necessary  to  refer  the  patient  to  a  laryngologist  for 
confirmation  of  the  opinion  or  for  treatment.  It  is  not  to  be  expected 
that  the  general  practitioner  should  be  familiar  wdth  such  new  requisi- 
tions as  the  tracheoscope  and  the  bronchoscope,  but  we  may  anticipate 
that  he  is  capable  of  rendering  the  larynx  accessible  by  means  of  the 
laryngoscope  and  perhaps  also  with  Kirstein's  spatula. 

The  symptomology  of  laryngeal  diseases  is  very  simple,  comprising 
hoarseness,  dyspnoea  and  difficulty  in  swallowing.  This  very  simplicity 
explains  the  impossibility  of  making  a  diagnosis  without  the  laryngo- 
scope, unless  the  history  and  extra-laryngeal  signs  declare  the  nature 
of  the  disease.  The  examination  should  invariably  be  concluded  with 
the  laryngoscope,  but  we  should  always  ascertain  as  much  as  we  can 
without  it. 

We  will  take  the  cases  as  they  occur  in  practice. 


DISEASES   OF  THE   RESPIRATORY   TRACT  III 


^.— ACUTE  DISEASES. 

(1)  INFLAMMATORY  PROCESSES   IN  THE   PHARYNX 
AND  LARYNX. 

Our  first  question  must  be  directed  to  the  manner  of  onset  of  the 
laryngeal  symptoms.  If  they  have  been  preceded  for  a  few  days  or 
even  only  for  a  few  hours,  by  a  general  feeling  of  malaise,  if  they 
began  with  difficult}^  in  swallowing  and  culminated  in  hoarseness  and 
dyspnoea  we  shall  at  once  suspect  an  acute  infectious  disease — 
a  pharyngeal  and  laryngeal  diphtheria.  The  younger  the  patient 
the  stronger  will  our  suspicion  be.  The  inexperienced,  however, 
sometimes  forget  that  this  disease  also  occurs  among  adults.  The 
instances  in  which  medical  practitioners  contract  diphtheria  as  a 
sacrifice  of  their  profession  are  well  enough  known. 

If  the  teuipcraiure  is  iionnal,  we  may  be  relieved  as  to  the  severity 
of  the  disease,  but,  despite  this,  we  cannot  exclude  true  diphtheria. 
Many  a  slight  case,  with  a  trifling  rise  in  temperature,  has  rapidly 
developed  huyngeal  obstruction.  Indeed,  I  would  go  further  and 
say  that  mild  fever  with  severe  local  symptoms  distinctly  indicate 
diphtheria,  because,  other  things  being  equal,  Loffler's  bacilli  do  not 
raise  the  temperature  as  much  as  streptococci  do. 

It  should  be  noted  incidentally  that  in  the  very  severe  cases,  the 
temperature  falls  to  the  degree  of  collapse,  after  a  preceding 
pyrexia.  The  gravity  of  the  general  condition  will  lead  to  a  correct 
conclusion. 

It  the  temperature  is  raised,  it  is  evident  that  there  is  some  infec- 
tion. The  examination  of  tlie  pharynx  will  supply  further  information. 
If  we  find  the  familiar  thick  whitish  deposit  upon  the  tonsils,  fauces 
and  even  on  the  posterior  pharyngeal  wall — a  deposit  which  can  be 
removed  as  shreds — we  diagnose  diphtheria — at  least  clinically.  In  the 
majority  of  cases  we  shall  be  correct,  and  bacteriological  examination 
will  reveal  the  presence  of  Loffler's  bacilli.  In  a  few  cases  the  bacterio- 
logical report  will  be — streptococci,  no  diphtheria  bacilli.  A  more 
careful  examination  of  such  cases  would  show  that  thei'e  was  no  real 
membrane  present,  but  merely  a  greasy  deposit  breaking  up  into 
shreds.  But  it  is  not  always  possible  to  make  a  very  careful  examina- 
tion of  an  excited  and  choking  child. 

I  have  nevertheless  seen  deposits  in  streptococcal  infection  which 
could  hardly  be  distinguished  clinically  from  those  of  true  diphtheria; 
but  these  cases  are  not  frequent.     They  occur  mostly  in  scarlet  fever. 

If  there  be  merely  white  specks  on  swollen  red  tonsils  we  must 
decide  whether  they  are  merely  plugs  of  pus  situated  within  the 
crypts    of    the    tonsils — follicular   tonsillitis,    or    whether    they    are 


112  SURGICAL   DISEASES    OF   THE   XECK 

accumulations  on  the  mucous  membrane  of  the  tonsils.  Only  the 
latter  are  or  can  be  diphtheritic.  I  say  "  can  be,"  because  strepto- 
cocci may  mislead  us  here  also.  It  is  not  difficult  to  distinguish 
between  plugs  within  the  follicles  and  superficial  fibrinous  infiltrate 
and  deposits,  with  careful  inspection  and  a  little  experience.  If  we 
do  not  succeed  in  making  the  distinction,  there  is  the  prospect  of 
the  little  specks  coalescing  into  an  undoubted  membrane,  while  the 
bacteriological  examination  is  being  made. 

If  the  tonsils  merely  present  a  diffuse  redness  without  any  white 
specks  at  all,  the  case  is  most  probably  one  of  ordinary  catarrhal 
tonsillitis,  but  diphtheria  is  by  no  means  excluded.  Every  practitioner, 
relying  upon  this  simple  redness,  has  reassured  the  parents  in  many 
a  case,  only  to  find  that  in  the  course  of  a  few  hours,  extreme  dyspnoea 
has  peremptorily  demanded  the  performance  of  tracheotomy.  This 
cannot  be  absolutely  excluded  even  when  nothing  has  been  found  in 
the  throat.  There  is  onlv  one  disease  which  occasions  parents  unneces- 
sary alarm — viz.,  false  croup.  A  child  who  has  been  running  about 
the  whole  clay  in  good  health,  becomes  suddenly  ill  at  night  with  a 
hacking  cough  and  symptoms  of  dyspnoea,  coming  on  in  paroxysms. 
On  examination,  the  temperature  is  normal  or  only  slightly  raised, 
the  throat  is  somewhat  reddened,  and  between  the  seizures  the  general 
condition  seems  to  be  good.  A  moist  compress  around  the  throat, 
the  inhalation  of  steam  and  a  mild  sedative  suffice  to  banish  all  the 
trouble  by  the  morning.  True  diphtheria  seldom  sets  in  so  rapidly, 
and  never  departs  so  quickly. 

Tlie  foregoing  leads  to  flie  conclusion  that  every  case  of  persistent 
dyspnoea,  however  mild.,  associated  with  general  malaise,  must  he  con- 
sidered as  serious.  If  there  are  at  the  same  time  symptoms  of  faucial 
diphtheria,  they  will  confirm  our  diagnosis  of  laryngeal  diphtheria ; 
but  their  absence  does  not  exclude  this  diagnosis. 

If  the  necessary  apparatus  is  at  our  disposal  and  if  we  are 
sufficiently  experienced  therein,  we  should  at  once  remove  some  of 
the  tonsillar  deposit  with  a  small  sterile  swab  and  make  a  cover-glass 
preparation  for  the  purpose  of  obtaining  confirmation  of  our  clinical 
diagnosis  or  justification  for  the  prophylactic  dose  of  serum  so  often 
administered  when  in  doubt.  In  definite  cases  the  bacilli  are  so 
abundant  that  no  doubt  can  remain.  But  in  all  cases  this  immediate 
examination  should  be  completed  by  making  cultures  in  a  bacterio- 
logical institute.  This  is  most  important  if  the  diagnosis  is  not 
already  rendered  probable  by  the  prevalence  of  an  epidemic  of 
diphtheria. 

We  should  certainly  not  await  the  result  of  a  bacteriological 
examination  as  an  indication  for  tracheotomy.  If  asphyxia  threatens, 
the  operation  must  be  performed  whether  Loffler's  bacilli  or  strepto- 
cocci are  in  question. 


DISEASES    OF   THE    RESPIRATORY   TRACT  II3 

There  are  a  few  secondary  symptoms  which  have  not  vet  been 
mentioned  but  which  deserve  consideration.  The  chief  one  of  these 
is  the  enlargement  of  the  glands  of  the  neck.  The  absence  of  this 
enlargement  is  not  evidence  against  diphtheria,  but  if  it  is  present,  the 
infection  is  a  severe  one  and  we  cannot  allow  ourselves  to  be 
consoled  with  the  idea  of  a  false  croup.  The  glands  do  not  indicate 
the  nature  of  the  infection,  although  they  enlarge  more  frequently  in 
diphtheria  than  in  streptococcal  sore  throat.  The  same  remarks 
apply  to   splenic  enlargement  and  to   alhinninnria. 

It  is  obvious  from  the  foregoing  that  to  confuse  diphtheria  and 
streptococcal  laryngitis  is  not  only  pardonable  but  is  often  unavoid- 
able. But  there  are  mistakes  which  should  be  avoided.  More  than 
once  has  an  incomplete  history  failed  to  elicit  the  presence  of  a 
foreign  bodv,  and  a  diagnosis  of  "  diphtheria  "  has  been  made.  In 
the  absence  of  an  epidemic  every  so-called  case  of  "croup"  which 
has  come  on  suddenly  without  any  prodroma,  should  remind  one 
of  the  possibility  of  a  foreign  body  and  the  historv  should  be  com- 
pletely investigated  from  this  point  of  view. 

Still  more  erroneous  is  its  confusion  with  pneumonia. 

A  little  child  was  brought  to  the  hospital  in  a  state  of  severe 
dyspnoea.  His  temperature  was  high,  and  he  was  evidently  very  ill. 
A  young  assistant,  who  was  much  struck  by  the  dyspnoea,  forthwith 
reported  the  case  as  one  of  croup  requiring  tracheotomy.  He  did 
not  notice  that  the  child  was  breathing  rapidly  without  any  stridor. 
A  more  careful  examination  showed  that  the  dyspnoea  was  due  to 
extensive  pneumonia. 

The  beginner  should  note  that  obstruction  of  the  upper  respiratory 
tract  s/tTit^s  the  breathing ;  diminution  of  the  respiratory  surface  as  in 
pneumonia  accelerates  the  breathing.  The  reason  for  this  is  very 
simple.  In  order  to  allow  the  same  amount  of  air  to  pass  through 
a  diminished  transverse  area  of  the  respiratory  tract,  a  prolongation 
and  a  deepening  of  the  respiratory  movements  are  required,  at  first 
at  the  expense  of  the  respiratory  pause.  As  the  difficulty  increases, 
more  work  is  thrown  upon  the  respiratory  muscles,  and  there  is  more 
necessity  for  intervals  of  rest.  The  breathing,  which  at  first  was 
only  deepened,  becomes  slowed  as  it  increases  in  urgency.  An 
accelerated  and  therewith  an  unavoidably  weakened  respiration  can 
only  suffice  when  the  respiratory  surface  is  diminished,  as  in 
pneumonia,  but  it  would  not  be  able  to  overcome  a  mechanical 
obstruction.  When  the  muscles  are  fatigued,  that  is  to  say,  in  a 
state  of  asphyxia,  there  may  be  a  relative  acceleration  of  the  breath- 
ing, even  if  there  is  mechanical  obstruction,  but  it  does  not  resemble 
the  hurried  respiration  of  pneumonia. 

In  addition  to  the  frequency  of  respiration  it  is  important  to  note 
the  presence  or  absence  of  dra\ving-in  of  the  soft  parts  of  the  thorax, 
the  root  of  the  neck,  the  supra-clavicular  fossae,  the  lower  thoracic 
segment,  and   of   the    epigastrium.     But  this    must  not  be  confused 


114  SURGICAL   DISEASES   OF   THE   NECK 

with  the  so-called  peri-pneumonic  retraction  of  the  lower  border  of 
the  Inng  in  young  children. 

It  might  appear  to  be  quite  superfluous  to  refer  to  these  well- 
known  matters ;  but  I  once  saw  a  doctor  blamed  bv  parents  for 
having  submitted  a  child  who  was  suffering  from  pneumonia  to 
tracheotomy.  Careful  attention  must  therefore  be  paid  to  these  signs 
in  every  doubtful  case,  and  doubtful  cases  can  occur  in  diphtheria. 
For  instance,  pneumonia  may  lead  to  dyspnoea  in  this  disease,  just 
as  well  as  extension  to  the  larynx  may.  It  is  therefore  necessary  to 
estimate,  to  which  of  the  two  factors  the  d3'spnoea  is  to  be  attributed. 
If  it  be  due  to  pneumonia,  vce  must  await  the  effect  of  the  serum, 
if  on  the  other  hand,  it  be  due  to  obstruction,  we  must  operate 
despite  the  pneumonia.  No  sign  is  more  conclusive  than  the  type 
of  the  breathing. 

The  association  of  ideas  by  which  laryngeal  obstruction  in  children 
at  once  suggests  diphtheria  may  lead  to  mistakes.  The  cause  of  the 
respiratory  difficulty  need  not  be  either  in  the  larynx  or  trachea,  but 
the  glottis  may  be  blocked  by  a  retro-pharyngeal  abscess.  Such 
an  abscess  is  often  tubercular,  and  starts  either  in  the  vertebral  column 
or  retro  -  pharyngeal  tubercular  glands.  Non  -  tubercular  retro- 
pharyngeal abscesses  are  usually  the  sequelae  of  scarlet  fever  or 
measles,  occasionally  of  erysipelas.  If  the  pharynx  is  examined  in 
every  case  of  "croup''  before  proceeding  to  tracheotomy,  these 
abscesses  will  not  be  overlooked.  The  experienced  observer  will 
already  have  suspected  a  vertebral  abscess  from  the  stiff  posture  in 
which  the  child  holds  the  head,  and  from  his  emaciated  miserable 
appearance,  so  clearly  described  by  Albert. 

Retro-pharyngeal  abscesses,  especially  of  the  tubercular  variety, 
obstruct  the  glottis  by  their  own  mass,  but  every  acute  inflammation 
in  the  neighbourhood  of  the  larynx  may  produce  a  similar  obstruc- 
tion by  exciting  an  inflammatory  oedema  of  the  entrance  to  the 
larynx,  a  so-called  oedema  of  the  glottis,  or  to  be  more  correct, 
laryngeal  cedema.  The  loose  submucous  tissue  may  swell  up  so 
rapidly  that  the  ary-epiglottic  folds  and  the  ventricular  bands  look 
like  cushions,  and  a  fatal  result  may  ensue  before  assistance  is  forth- 
coming. Any  infective  process  in  the  throat,  acute  abscesses, 
phlegmons  or  erysipelas  may  be  responsible  for  this  condition  or  it 
may  originate  in  a  small  wound  caused  by  a  pointed  foreign  body. 
Not  a  year  passes  without  accounts  of  persons  being  suft'ocated 
before  help  is  available,  through  swallowing  a  bee  or  a  wasp  with 
fruit  or  juice,  and  being  stung  by  the  insect.  OEdema  of  the  larynx 
may  also  occur  after  operative  procedures  in  the  neighbourhood  of  the 
throat  ;  therefore  patients  who  are  threatened  by  this  danger  should 
be  most  carefully  watched. 

This  brings  us  to  the  so-called   laryngeal   perichondritis,  whose 


DISEASES   OF   THE   RESPIRATORY   TRACT  II5 

chief  danger  is  the  development  of  acute  laryngeal  oedema.  This  is 
not  a  primary  disease,  it  is  always  the  consequence  of  a  deep  laryngeal 
ulcer  of  some  kind,  or  it  may  be  a  uietaslalic  process.  Such  ulcers 
occur  in  infiltrating  injuries,  typhoid  fever,  small  pox,  tubercle, 
syphilis,  cancer,  &c.,  and  suppurating  metastases  are  met  with  in  the 
course  of  typhoid,  small  pox,  scarlet  fever,  and  pyaemic  diseases  from 
any  source. 

If  hoarseness  and  dyspnoea  occur  in  any  of  these  diseases,  and 
there  are  at  the  same  time  external  swelling  and  pain  on  pressure  over 
the  whole  or  part  of  the  larynx,  we  must  think  of  perichondritis.  The 
laryngoscope  will  reveal  the  presence  of  ulcers,  abscesses,  and 
cedematous  areas  in  very  varied  distribution. 

(2)  PURE  CIRCULATORY  DISTURBANCES. 

ffidema  of  the  larynx  may  exist,  independently  of  any  inflamma- 
tory disease,  merely  as  a  consequence  of  a  pure  circulatory  disturbance. 
It  may  occur  as  a  part  of  a  general  oedema  due  to  circulatory  disease, 
or  nephritis,  and  as  a  result  of  new  growths  in  the  vicinity  of  the 
vessels  of  the  neck,  and  finally  as  a  variety  of  angio-neurotic  cedema. 
This  latter  occurs  in  various  parts  of  the  body,  either  in  the  form  of 
large  urticarial  wheals  of  the  skin  or  mucous  membrane,  or  as 
cedematous  swelling  of  extensive  skin  areas.  Sometimes  the  cause  is 
not  apparent,  but  sometimes  it  follows  indulgence  in  certain  food, 
just  as  in  the  case  of  urticaria.  In  a  patient  of  mine  it  always 
followed  the  use  of  white  wine.  Occasionally  a  hereditary  predis- 
position exists.  Its  localization  in  the  larynx  is  not  by  any  means 
a  very  rare  event,  but  its  danger  is  diminished  by  its  usually  short 
duration.  In  spite  of  this,  however,  it  is  quite  conceivable  that  it 
would  be  fatal,  if  the  obstruction  of  the  glottis  were  complete. 
Indeed,  death  has  resulted  in  such  a  case  because  medical  assistance 
was  not  immediately  available.  But  sometimes  the  oedema  disappears 
as  rapidly  as  it  comes,  even  in  the  very  presence  of  all  the  preparations 
made  for  tracheotomy.  We  must  probably  include  in  this  category 
those  cases  of  laryngeal  oedema  which  have  been  observed  in  persons 
with  an  idiosyncrasy  towards  iodide  of  potassium.  Asphyxia  has  even 
been  observed  in  such  cases. 

The  diagnosis  is  not  difficult  in  cases  of  angio-neurotic  oedema, 
because  the  patients  are  usually  aware  of  the  nature  of  their  malady 
and  are  able  to  provide  their  own  diagnosis  quite  accurately.  It  is 
quite  different  in  the  cases  of  idiosyncrasy  towards  iodide  of  potas- 
sium. In  every  case  of  unexplained  laryngeal  oedema,  enquiries 
should  be  directed  towards  the  administration  of  some  form  of  iodine, 
if  we  have  not  ourselves  prescribed  it. 

The  diagnosis   of  laryngeal  oedema   is  easy  enough.     It  is   quite 


Il6  SURGICAL   DISEASES   OF   THE   NECK 

possible  to  feel  with  the  finger  the  two  soft  swellings  which  block  up 
the  entrance  to  the  larynx,  and  a  careful  examination  with  the 
laryngoscope  reveals  an  unmistakable  picture. 

(3)  INJURIES. 

Swellings  of  an  inflammatory  and  circulatory  character  do  not 
exhaust  all  the  causes  of  acute  dyspnoea.  An  external  blow  or  stroke 
may  lead  to  fracture  of  a  cartilage,  whether  it  be  ossified  or  not,  and 
the  hematoma  resulting  therefrom  is  liable  to  obstruct  the  glottis  in 
a  very  short  time.  The  presence  of  unnatural  movement  on  careful 
external  palpation,  surgical  emphysema  and  the  view  of  the  hsematoma 
with  the  laryngoscope  permit  us  to  make  the  diagnosis.  The  most 
varied  injuries  of  the  respiratory  tract  may  cause  asphyxia  by  means 
of  surgical  eiiiphvsenin. 

(4)   FOREIGN   BODIES  IN  THE  AIR  PASSAGES. 

The  practitioner  often  sees  another  cause  for  sudden  dyspncea,  in 
the  inhalation  of  foreign  bodies.  We  can  realize  the  things  which 
have  been  found  in  the  air  passages,  if  we  think  of  what  children  put 
in  their  mouths  and  of  what  adults  hold  between  their  lips  for  con- 
venience. Beans,  peas,  glass  beads,  bits  of  bone  are  of  the  most 
frequent  occurrence;  nails,  needles,  and  shirt  buttons  testify  to  the 
bad  habit  of  using  the  lips  as  prehensile  organs.  Even  pieces  of 
dentures  have  found  their  way  between  the  vocal  cords,  an  incident 
which  should  always  suggest  unconscious  inhalation  in  epileptic 
attacks. 

If  the  circumstances  point  to  the  possibility  of  a  foreign  body 
having  been  inhaled,  we  must  first  find  out  whether  it  is  really  in  the 
air  passages.  If  it  is  acknowledged  that  it  was  put  into  the  mouth, 
and  this  was  followed  by  a  severe  attack  of  coughing  and  the  vomiting 
of  blood-stained  phlegm,  the  probability  is  that  the  foreign  body  was 
in  the  air-passages,  but  it  may  have  been  expelled  by  the  coughing. 
The  patient  may  still  feel  it  there  for  a  very  long  time,  varying  with 
his  sensitiveness  and  the  amount  of  injury  inflicted  on  the  mucous 
membrane — at  any  rate  for  a  few  hours.  It  there  is  no  dyspnoea, 
there  is  ample  time  to  use  the  laryngoscope.  A  negative  finding,  the 
disappearance  of  the  cough  without  any  artificial  aid,  and  the  absence 
of  any  lung  symptoms  suffice  to  reassure  us.  A  foreign  body  situated 
more  deeply,  i.e.,  in  the  trachea,  manifests  itself  by  attacks  of  coughing 
which  are  incited  either  on  the  under  surface  of  the  vocal  cords  or  at 
the  bifurcation  of  the  trachea.  A  foreign  body  in  the  bronchus  will 
assert  itself  by  pulmonary  symptoms  on  the  corresponding  side. 


DISEASES   OF   THE   RESPIRATORY   TRACT 


117 


The  accuracy  of  this  last  statement  should  be  qualified.  A  foreign 
body  may  remain  in  bronchus  for  a  day  or  two  without  causing  any 
symptoms.  Thus  I  saw  a  youth  who  confessed  to  having  swallowed 
a  lead-pencil  case,  but  who  distinctly  denied  having  any  respiratory 
inconvenience  at  the  moment  of  swallowing  it — this  he  did  in  order 
to  put  his  fault  in  as  favourable  a  light  as  possible.  It  turned  out 
afterwards  that,  as  a  matter  of  fact,  he  had  a  severe  attack  of  suffoca- 
tion. After  the  foreign  body  had  entered  the  bronchus,  there  were  no 
more  subjective  symptoms,  but  two  days  later  the  pneumonia  which 
supervened,  and 
the  skiagram, 
showed  that  the 
metal  case  was  in 
the  left  main  bron- 
chus. It  was  suc- 
cessfully removed 
with  the  foreign 
body  forceps, 
through  a  trache- 
otomy incision. 

If  there  is  a 
persistent  or  par- 
oxysmal cough, 
without  any  sign 
in  the  larynx,  we 
must  listen  for  a 
fluttering  sound 
in  the  trachea.  If 
this  should  be 
heard,  it  signifies 
that  the  foreign 
body  is  being 
wafted  between 
the  larynx  and  the 
bifurcation,  with 
each  breath,  and 
that  the  cough 
is    being    excited 

from  both  positions.  Such  a  case  will  be  further  elucidated  by 
tracheotomy,  when  the  offending  substance  may  fly  out  with  the 
first  cough.  If  this  does  not  happen  we  must  look  for  it  with  the 
laryngoscope  introduced  into  the  trachea. 

If  the  foreign  body  cannot  be  seen  in  the  larynx,  but  is  of  such 
a  nature  as  permits  of  its  demonstration  by  X-rays,  this  measure 
must  not  be  neglected  (fig.  63).  If  this  yields  no  result  and  the 
coughing  still  persists,  we  must  either  undertake  a  tracheotomy,  with 


Left. 

Fig.   63. — Metal  case  in  end  of  left  main  bronchus, 
extensively  thickened  (pneumonia). 


Right. 
Lung  tissue 


Il8  SURGICAL   DISEASES   OF   THE   NECK 

some  misgiving,  or  refer  the  case  to  an  expert  in  tracheoscopy  and 
bronchoscopy. 

The  procedure  must  be  quite  different,  if  there  is  definite  dyspncea 
from  the  start.  All  diagnostic  speculations  must  be  abandoned  and 
the  urgent  demand  of  the  moment  must  be  satisfied.  When  the 
patient  can  again  breathe  and  our  diagnosis  is  still  unformed,  the 
Rontgen  rays  and  bronchoscopy  may  be  invoked. 

We  have  hitherto  assumed  that  the  dyspnoea  is  caused  by  the 
foreign  body  being  situated  in  the  air-passages  ;  but  this  is  not  always 
the  case.  I  once  had  an  epileptic  on  the  operation  table,  who  suffo- 
cated himself  through  swallowing  his  tooth-plate.  It  pressed  from 
behind  on  the  trachea,  and  I  had  to  do  tracheotomy  before  there  was 
time  to  open  the  oesophagus  to  remove  the  plate. 

5.— CHRONIC    DISEASES. 

The  problems  are  quite  different  if  the  laryngeal  symptoms  have 
come  on  gradually,  in  which  circumstance  the  previous  history  is  of 
the  greatest  importance. 

A  remark  of  a  non-surgical  character  is  worth  making  here.  If  a 
young  or  middle-aged  person,  who  is  neither  a  drinker,  a  heavy 
smoker,  nor  a  speaker,  and  is  otherwise  healthy,  becomes  persistently 
hoarse,  the  possibility  of  syphilis  should  be  thought  of,  especially 
the  catarrhal  hoarseness  of  the  secondary  stage. 

If  the  trouble  has  begun  with  hoarseness,  and  there  has  developed, 
in  the  course  of  months,  a  persistent  or  paroxvsmal  dyspnoea,  with 
difficulty  in  swallowing,  ^7  tumour  or  ulcer  of  tlie  larvux  must  be 
suspected.  We  must,  of  course,  be  sure  that  we  are  not  mistaking 
a  tumour  of  the  neck,  such  as  a  malignant  growth  of  the  thyroid  or 
adjacent  region,  or  a  retropharyngeal  tubercular  abscess,  for  a  laryngeal 
disease.  A  careful  examination  is  necessary  for  this  purpose.  A  small 
cancer  of  the  thyroid  may  cause  hoarseness  by  paralysing  the  recurrent 
laryngeal  nerve  and  its  pressure  may  cause  both  dyspnoea  and  difficulty 
in  swallowing.  This  last  diff'ers  in  character  from  the  same  symptoms 
as  caused  by  laryngeal  ulcers,  because  the  difficulty  of  swallowing  is 
due  to  a  uwcliauical  obstacle,  whereas  in  laryngeal  disease  the  paiu  of 
tJie  act  of  sivatlowiu^  is  the  real  subject  of  complaint. 

The  true  nature  of  the  disease  can  often  be  suspected  before  resort- 
ing to  the  laryngoscope.  We  need  not  liesitate  about  diagnosis  if  a 
typically  tubercular  looking  patient  states  that  he  has  been  hoarse  for 
years,  brings  up  blood  and  suffers  from  night  sweats.  Of  course  a 
consumptive  may  have  syphilis  or  cancel-,  but  the  long  duration  of 
the  symptoms  excludes  the  latter,  and  the  syphilitic  factor  can  be 
cleared  up  by  means  of  Wassermann's  test  and  specific  treatment. 
It  takes  a  year  or  more  for  a  tubercular  ulcer  to  effect  the  damage 


DISEASES    OF    THE    RESPIRATORY    TRACT  II9 

which  cancer  can  do  in  a  few  iiioiitlis,  or  a  gummatous  ulcer  in  a  few 
weeks.  The  most  significant  point  in  the  history  of  tubercle  is  the 
early  onset  of  pain  on  swallowing,  which  is  occasionally  much  more 
pronounced  than  difficulty  in  breathing. 

Too  much  deference  must  not  be  paid  to  the  previous  history,  to 
the  neglect  of  careful  examination.  The  following  case  wdll  convey 
this  moral. 

A  remarkably  healthy  young  woman,  hardly  30  years  of  age, 
sought  advice  about  difficulty  in  swallowing,  which  had  persisted  for 
some  months,  but  which  had  lately  become  worse.  Her  main 
symptoms  were  pain  and  a  feeling  of  soreness.  The  laryngoscope 
showed  an  ulcer  between  the  arytenoid  cartilages,  spreading  towards 
the  back  of  the  larynx.  Syphilis  could  be  excluded  and  the  case 
appeared  to  be  clinically  tubercle,  but  the  microscopical  examination 
of  a  small  piece  of  the  margin  of  the  ulcer  declared  it  to  be  carcinoma. 
Before  the  patient  agreed  to  an  operation  she  was  suddenly  attacked 
by  aspiration  pneumonia.  In  this  case  the  position  of  the  ulcer  was 
certainly  unusual  for  tubercle,  and  its  situation  in  the  inter-arytenoid 
region  towards  the  back  of  the  larynx  might  have  suggested  the 
possibility  of  carcinoma.  Since  then,  I  have  seen  a  similar  case,  also 
m  a  young  female  patient.  It  should  be  added  that  Sendziak's 
statistics  show  that  cancer  in  this  particular  situation  is  much  more 
frequent  in  women  than  in  men. 

If  a  healthy  man  of  middle  or  advanced  age  begins  to  get  hoarse, 
and  if  this  hoarseness,  after  some  months,  is  accompanied  by  some 
slight  difficulty  in  breathing,  we  should  think,  instinctively,  of  cancer 
and  examine  the  neck  for  hard,  enlarged  glands.  The  absence  of 
such  glands  is  no  argument  aoaiiisf,  but  their  presence  is  a  strong 
evidence  for  it,  provided  of  course  that  this  glandular  enlargement  is 
recent.  A  pronounced  foetor  ex  ore  is  also  in  favour  of  cancer,  because 
this  symptom  is  very  rare  in  other  ulcers.  Some  support  to  the 
diagnosis  is  afforded  by  the  knowledge  that  the  patient  is  a  lover  of 
the  bottle.  Usually  tobacco  is  blamed  quite  confidently  ;  people  prefer 
to  be  knowm  as  inveterate  smokers  rather  than  as  strong  drinkers. 

Age  plays  so  important  a  role  in  regard  to  cancer  of  the  larynx, 
that  chronic  hoarseness  coining  on  in  a  man  over  50  ninsl  be  suspected  to 
be  due  to  cancer. 

But  at  the  same  time  we  must  discard  all  preconceived  ideas,  as 
the  following  case  shows. 

An  old  man  was  sent  to  the  surgeon  with  the  diagnosis  of  cancer, 
because  he  was  suffering  from  hoarseness  and  difficulty  in  swallowing. 
The  surgeon  refused  to  operate,  and  for  a  good  reason,  because 
despite  a  late  appearance,  the  patient  had  pronounced  pulmonary 
tuberculosis,  and  his  ulcer  was  not  cancerous  but  tubercular. 

If  the  patient  states  at  once  that  he  has  had  syphilis,  we  must  not 
forthwith  conclude  that  he  has  a  gummatous  ulcer,  but  we  should, 


120  SURGICAL   DISEASES   OF   THE   NECK 

at  any  rate,  institute  specific  treatment.  The  propriety  of  this  course 
would  be  confirmed  if  the  patient  is  neither  tubercular,  nor  at  the 
cancer  age,  if  glandular  enlargement  is  absent  and  if  the  subjective 
complaints  are  slight,  and  above  all  if  other  traces  of  tertiary  syphilis 
can  be  detected. 

The  history  and  the  general  condition  having  put  us  on  the  tracks 
we  must  next  proceed  to  an  examination  with  the  laryngoscope. 

The  situation  of  the  lesion  is  full  of  suggestion.  Tubercle  prefers 
the  vocal  cords,  the  neighbourhood  of  the  arytenoids,  and  less 
frequently  the  epiglottis.  Svphilis  rather  prefers  the  latter  situation,, 
but  may  occur  anywhere  in  the  larynx.  Cancer  is  most  frequently 
found  on  the  vocal  cords  and  then  in  decreasing  frequency,  on  the 
ventricular  bands,  the  epiglottis,  and  the  posterior  wall  of  the  larynx. 

The  greatest  care  is  required  in  basing  a  diagnosis  on  the  clinical 
features  of  the  disease.  All  the  three  forms  may  start  as  nodules,  and 
all  three  subsequently  ulcerate.  If  there  are  a  number  of  nodules^ 
present,  we  should  think  of  tubercle  or  gumma  rather  than  of  cancer. 
A  cauliflower-like  shaggv  appearance  indicates  cancer.  That  it  is  not 
easy  for  the  inexperienced  to  decide  from  the  appearance  of  the  ulcer 
is  obvious  enough  if  we  consider  the  difficulty  which  even  the 
experienced  find  in  diagnosing  an  ulcer  of  the  oral  mucous  membrane, 
quite  accessible  to  the  eye.  The  rules  we  have  already  mentioned 
in  connection  with  the  latter  ulcers  also  .  apply  in  this  instance. 
Ulcers  and  growths  which  extend  beyond  the  boundaries  of  the 
larynx,  encroaching  upon  neighbouring  organs,  are  most  likely  can- 
cerous. In  such  cases,  evidence  of  a  hard  margin  and  base,  which 
can  easily  be  obtained  by  palpation,  is  often  of  decisive  significance. 

Often  enough  the  laryngoscope  does  not  permit  us  to  get  beyond 
the  mere  diagnosis  of  "  ulcer."  Three  other  methods  may  then  be 
resorted  to  ;  histological  and  bacteriological  examination  and  thera- 
peutic experiment. 

The  piece  submitted  to  histological  examination  should  not  be  too 
small.  It  maybe  removed  by  the  practitioner  if  he  possesses  sufficient 
dexterity,  otherwise  this  procedure  should  be  carried  out  by  the 
laryngologist.  It  is  most  important  that  the  piece  should  be  snipped 
off  the  right  place.  An  error  in  this  respect  may  be  disastrous  in  its 
consequences,  as  testified  by  a  famous  historical  instance  which  it  is 
unnecessary  to  recall. 

Thei'e  is  no  difficulty  in  recognizing  cancer  under  the  microscope. 
The  distinction  between  tubercle  and  syphilis  may  be  rather  difficult 
if  there  is  no  pronounced  general  tuberculosis  present ;  but  here  the 
gap  will  be  supplied  by  bacteriological  examination.  It  may  be  possible 
to  detect  tubercle  bacilli  by  rubbing  the  surface  of  the  ulcer  with  a 
laryngeal  probe  covered  with  cotton  wool,  and  wiping  the  wool  on 
a  cover  glass.     Animal   inoculation  with  a  portion  of  test  specimen 


DISEASES    OF   THE    RESPIRATORY    TRACT  121 

1-emoved  is,  however,  a  much  more  certain  method.  The  experiment 
of  treatment  with  iodide  of  potassium  must  be  regarded  as  an  ultimate 
resort,  if  Wassermann's  reaction  is  positive. 

It  happens  sometimes  that  although  the  symptoms  have  led  us  to 
suspect  tubercle,  syphilis,  or  cancer,  the  laryngoscope  reveals  a  sharply 
circumscribed  structure,  situated  on  a  vocal  cord  or  on  the  anterior 
commissure,  with  absolutely  no  morbid  change  round  about.  This 
is  in  all  probability  an  innocent  growth,  and  if  it  is  smooth  on  its 
surface  like  a  pea,  or  somewhat  rough,  from  being  an  aggregation  of 
separate  roundish  little  nodules,  it  may  be  regarded  as  a  fibroma. 
If  the  growth  looks  like  a  cauliflower,  or  a  condyloma  with  points, 
it  is  to  be  regarded  as  a  papilloma.  Such  papillomata  do  not 
alwavs  exist  in  the  form  of  circumscribed  tumours,  they  may  extend 
superiiciallv  just  like  papillomata  of  the  bladder. 

Can  these  innocent  tumours  not  be  diagnosed  clinically  f  In 
some  cases,  certainly  they  can  ;  in  cases  wherein  the  growth  is 
pedunculated  and  gets  caught  occasionally  between  the  cords.  The 
history  will  show  that  the  patient  sometimes  has  a  clear  voice,  and 
then  suddenly  gets  attacked  by  hoarseness  or  even  seized  by  suffoca. 
tion.  If  a  child  suffers  from  luiexplained  persistent  hoarseness,  or 
from  repeated  attacks  of  unexplained  suffocation,  we  should  think 
of  a  papilloma,  because  this  is  not  at  all  a  rare  condition  in  children, 
and  is  practically  the  sole  laryngeal  tumour  which  occurs  among 
them. 

Errors  in  diagnosis  in  respect  to  innocent  laryngeal  tumours  may 
be  made  in  various  directions.  A  circumscribed  tubercular  or  gum- 
matous nodule  may  be  mistaken  for  a  fibroma,  or  vice  versa,  but  the 
further  course  of  the  case  would  however  clear  this  up.  In  other 
cases  we  may  be  doubtful  whether  a  papillary  structure  which  we 
have  discoved  is  innocent  or  malignant.  Age  is  of  course  of  great 
significance  here,  for  a  papilloma  in  an  old  man  is  always  suspicious 
of  cancer,  and  if  enlarged  hard  glands  are  present,  the  matter  is  con- 
clusive. One  must  never  wait  for  enlarged  glands  to  confirm  the 
diagnosis  before  operating,  because  in  cancer  of  the  larynx  the  glands 
aie  often  very  late  in  appearing.  When  in  doubt  the  only  course  to 
pursue  is  to  have  an  adequate  portion  excised  for  examination. 

There  are  some  rare  laryngeal  tumours  which  cannot  usually  be 
diagnosed  until  after  their  removal.  The  practitioner  cannot  be 
expected  to  recognize  these  accurately.  The  same  applies  to  tumours 
of  the  trachea.  It  may  be  mentioned  as  a  curiosity  that  new  growths 
ci'ith  the  strnctnre  of  the  thyroid  gland  have  been  found  in  it,  obviously 
arising  from  a  misplaced  thyroid  rudiment.  Sarcoma  occurs  more 
frcquentlv,  and  therefore  has  more  practical  importance.  The  dia- 
gnosis of  a  tumour  of  the  trachea  is  made  by  a  process  of  exclusion^ 


122  SURGICAL    DISEASES    OF    THE    NECK 

if  no  other  explanation  for  the  difficulty  in  breathing  is  forthcoming. 
An  expert  in  the  use  of  the  laryngoscope  may  be  able  to  see  the 
tumour  even  in  this  situation.  If  unsuccessful  at  first  the  patient 
must  give  several  sittings  in  order  to  become  gradually  accustomed 
to  the  examination,  as  is  so  often  necessary  when  laryngoscopy  is 
not  well  tolerated. 

It  must  be  mentioned  that  tumours,  especially  cancer,  in  the 
vicinity,  may  infiltrate  the  trachea,  and  grow  in  a  fungiform  manner. 
As  a  rule,  by  the  time  a  primary  cancer  has  manifested  symptoms 
pointing  to  the  trachea,  it  has  already  declared  itself  in  other  ways, 
so  that  the  diagnosis  is  attended  by  no  difficulty. 


CHAPTER   XXI. 
DIFFICULTY    IN    SWALLOWING. 

In  accordance  with  an  old  and  useful  rule,  we  must  distinguish 
the  difficulty  in  swallowing  caused  by  some  disturbance  of  the 
mechanism  in  the  mouth  or  throat,  from  the  difficulty  caused  by 
obstruction  in  the  oesophagus.  Obviously  this  difference  implies  the 
existence  of  very  different  conditions. 

.4.— DISTURBANCES    OF   THE    MECHANISM 
OF    SWALLOWING    IN    THE   MOUTH    AND   THROAT. 

Deglutition  may  be  deranged  in  various  ways  : 

(i)  Paralysis  of  ilic  muscles  of  Ihe  palate.  In  order  to  swallow 
efficiently  it  is  necessary  that  the  upper  portion  of  the  pharynx  should 
be  shut  off  by  the  action  of  the  soft  palate.  If  the  latter  is  paralysed 
it  follow's  that  some  of  the  food  will  gain  access  to  the  nose  by  escap- 
ing upwards.  This  upward  flow  will  not  affect  the  food  alone,  it  will 
also  affect  the  current  of  air  during  speech,  and  therefore  the  nasal 
intonation  of  the  patient  will  suggest  the  cause  of  the  difficulty  in 
swallowing,  before  even  we  make  an  examination.  Paralysis  of  the 
palate  after  diphtheria  is  a  classical  example  of  this  condition.  The 
paralytic  symptoms  in  bulbar  palsy  are  much  more  extensive,  but  in 
this  disease  the  difficulty  in  deglutition  is  preceded  by  many  other 
paralytic  symptoms  which  will  already  have  established  the  diagnosis. 

(2)  Congenital  or  inherited  defects  in  the  development  of  the  soft 


DIFFICULTY   IN    SWALLOWING 


123 


palate  may  interfere  with  the  act  of  deghitition,  just  Hke  paralysis 
The  former  condition  is  usually  associated  with  a  cleft  of  the  hard 
palate,  and  the  latter  is  the  result  of  gnuiniatoiis  destruction,  but  a 
patient  with  cleft  palate  is  more  or  less  able  to  compensate  for  his 
disability  by  raising  his  tongue  to  close  the  fissure. 

(3)  Scats,  especially  after  tertiary  syphilis,  more  rarely  after  burns 
and  corrosions,  may  interfere  with  the  mobility  of  the  palate  and  thus 
prevent  the  effectual  shutting  off  of  the  pharyjix. 

(4)  Pain  is  a  frequent  cause  of  difficulty  in  swallowing,  for  when 
severe  it  may  completely  inhibit  deglutition  by  reflex  action.  Every 
layman  recognizes  the  difficulty  in  swallowing  in  cases  of  sore  throat ; 
but  it  is  also  a  special  complication  of  laryngeal  tuberculosis,  as  also 
of  laryngeal  and  pharyngeal  cancer.  In  tubercle,  the  difficulty  may 
be  so  great  that  feeding  becomes  almost  impossible.  The  difficulty 
in  swallowing  when  a  foreign  body  is  in  the  throat,  especially  in  the 
pyriform  fossa,  is  also  due  to  the  inhibition  caused  by  the  pain. 

(5)  Apart  from  the  inhibition  caused  by  pain  as  just  mentioned, 
acute  inftaininatory  processes  interfere  with  the  act  of  deglutition,  and 
may  even  render  it  impossible.  This  is  due  to  inflammatory  infil- 
tration of  the  soft  palate,  to  diffuse  swelling  of  the  entire  throat,  and 
to  extreme  bulging  of  the  affected  side,  if  an  abscess  has  formed. 
The  swelling  in  phlegmonous  inflammation  of  the  floor  of  the  mouth 
and  of  the  tongue  causes  a  similar  disturbance. 

(6)  Swallowing  may  be  mechanically  prevented  by  pharyngeal 
tiunours  of  various  kinds,  such  as  naso-pharyngeal  polypi,  uaso-pharyn- 
geal  pbromata,  retro-pharvngeal  tumours  and  uialigiiant  growths  in  any 
part  of  the  throat.  A  chronic  retro-pharyngeal  abscess,  generally 
tubercular,  acts  in  the  same  way. 

(7)  The  presence  of  a  foreign  body  in  the  upper  part  of  the  pharynx 
also  acts  as  a  mechanical  obstacle  to  deglutition. 

The  circumstances  attendant  upon  the  case  will  put  some  limit 
on  the  above  mentioned  possibilities,  even  before  we  examine  the 
patient's  throat. 

A  sudden  onset  of  ditliculty  in  swallow^ing,  in  a  healthy  person,, 
indicates  a  foreign  body,  for  which  search  must  at  once  be  made, 
either  with  the  laryngoscope  or  the  finger.  If  a  foreign  body  is 
present,  it  is  probably  situated  in  the  sinus  pyriformis,  or  behind 
the  larynx  above  the  cricoid  cartilage.  I  have  seen  a  slice  of  raddish 
sticking  there  on  one  occasion,  and  on  another,  two  pieces  of  tough 
unmasticated  tongue. 

If  the  trouble  has  come  on  gradually,  or  at  any  rate  has  not  come 

on  within  an  hour  or  two,  the  age  must  be  taken  into  consideration 

first   of   all.     Palatal    paralysis  in    a   child  will  suggest  a  sequela   of 

diphtheria  ;   in  an  adult  it  will  point  to  bulbar  palsy.     If  the  difficulty 

9 


124  SURGICAL   DISEASES   OF   THE   NECK 

seems  to  be  due  to  a  tumour,  a  retro-pharyngeal  abscess  is  the  most 
likely  cause  in  a  child,  in  a  young  person  a  naso-pharyngeal  fibroma 
is  probably  responsible,  and  after  50  the  chances  are  in  favour  of  a 
malignant  neoplasm. 

The  I'oicc  is  very  characteristic.  A  nasal  tone  means  that  the 
palate  does  not  close  up  the  pharynx  satisfactorily,  owing  either 
to  paralysis  or  structural  defect.  If  the  voice  is  hoarse,  we  think 
instinctively  of  laryngeal  tuberculosis  in  young  people,  and  of  carci- 
noma in  those  of  a  more  advanced  age.  But  first  impressions  must 
not  be  permitted  to  lead  us  astray,  they  are  only  of  value  as  initial 
guides,  as  the  two  cases  previously  noted  will  exemplify  (p.  119). 

Having  made  a  provisional  diagnosis  from  the  history  and  the 
external  circumstances,  we  next  proceed  to  an  exaniiuaiion  of  the 
mouth  and  tJiroat.  Often  enough,  one  glance  into  the  open  mouth 
suffices  for  a  diagnosis.  A  lax,  dependent  soft  palate,  remaining  so 
even  on  phonation,  indicates  paralysis.  Sore  throat  and  retro- 
tonsillar  abscess  are  obvious  at  once.  In  retro-pharyngeal  abscess 
the  posterior  wall  of  the  throat  bulges  forward.  If  nothing  abnormal 
is  seen,  we  must  palpate  the  post-nasal  space,  and  finally  bring  the 
laryngoscope  to  our  aid.  If  nothing  still  appears,  we  must  con- 
clude that  the  trouble  is  not  in  the  throat  but  in  the  region  of  the 
oesophagus. 


5.— DISTURBANCES  OF  THE  MECHANISM  OF  DEGLU- 
TITION IN  THE  REGION  OF  THE  (ESOPHAGUS. 

We  now  come  to  the  second  and  a  most  important  of  deglutition 
troubles,  to  those  which  depend  upon  diseases  of  the  oesophagus  ami 
its  viciuify. 

(i)  If  the  difficulty  lias  occunrd  suddenly,  we  must  first  think  of  a 
foreign  body  in  the  throat.  In  a  large  number  of  cases  it  will  be 
found  that  artificial  teeth,  pieces  of  bone  or  coins,  have  been  swal- 
lowed. But  clear  as  the  history  is  in  some  cases,  in  others  we  can 
elicit  nothing  of  value.  An  epileptic  who  misses  his  artificial  plate 
after  an  attack  will  look  for  it  everywhere  except  in  his  oesophagus, 
as  long  as  he  feels  no  discomfort.  I  have  myself  seen  a  case  wherein 
an  agricultural  labourer  swallowed  a  piece  of  a  goat's  skull  with  his 
soup,  and  at  first  paid  no  heed  to  the  incident.  A  child  who  has 
swallowed  a  coin,  even  if  able  to  speak,  will  only  vouchsafe  informa- 
tion about  his  misdeed  when  he  finds  himself  in  difficulties.  So  that 
even  if  there  be  no  history  available,  the  sudden  onset  of  difficulty  in 
swallowing  should  always  arouse  first,  the  suspicion  of  a  foreign  body. 
But  how  can   the    diagnosis    be  established  ?      If    the    epileptic   just 


DIFFICULTY   IN    SWALLOWING  12$ 

referred  to,  consults  us  a  couple  of  days  after  he  has  missed  his 
plate,  because  he  is  quite  unable  to  swallow,  and  some  inflammation 
is  already  beginning,  we  are  forthwith  in  a  position  to  tell  him  the 
whereabouts  of  the  lost  object.  But  in  the  absence  of  such  clear 
indications,  we  ask  the  patient  to  take  a  little  drink  carefully,  and 
point  out  the  site  of  any  pain  which  may  be  present.  But  some 
caution  is  required  in  this  matter,  because  the  localization  of  pain  is 
limited  to  the  upper  portion  of  the  oesophagus,  and  even  if  pain  is 
ascribed  to  some  definite  spot  in  the  throat,  this  only  suggests  that 
some  injury  has  occurred  there,  and  not  that  the  foreign  body  is  to  be 
found  there.  We  next  proceed  to  pass  a  sound,  beginning  with  a 
soft  india-rubber  one  for  the  sake  of  gentleness.  If  this  should  be 
held  up  in  its  passage  downwards,  it  will  afford  approximate  informa- 
tion as  to  the  site  of  the  obstruction.  A  very  flexible  whale-bone 
sound  gives  more  reliable  information.  If  it  is  conjectured  that  the 
foreign  body  has  been  swallowed  a  day  or  two  previously,  or  even 
before  that,  the  most  extreme  care  will  be  required,  lest  inflammatory 
change  has  already  supervened.  In  any  case  we  should  begin  with  a 
sponge  sound,  after  assuring  ourselves  that  the  sponge  has  been 
carefully  cleansed  and  fits  in  firmly. 

Accidents  may  happen  even  to  the  most  expert  in  the  passing  of 
oesophageal  bougies.  Kocher  had  a  case  wherein  he  had  to  remove 
a  piece  of  a  whale-bone  sound  by  gastrotomy.  It  was  the  first 
operation  of  the  kind,  deliberately  carried  out  on  a  stomach  not 
secured  by  adhesions. 

If  we  come  to  an  obstruction  on  carefully  pushing  the  sponge 
sound  forwards,  we  must  not  proceed  further,  but  withdraw  it,  and 
see  whether  there  be  any  blood  or  pus  on  it.  It  will  sometimes  be 
necessary  to  wipe  the  sponge  on  a  cover  glass,  and  stain  with 
methylene  blue,  in  order  to  detect  the  pus.  We  may  next  use  a 
firmer  sound,  which  will  permit  us  to  estimate  the  distance  of  the 
obstruction  from  the  upper  teeth,  better  than  is  possible  with  a  soft 
sound.  If  we  know  the  nature  of  the  foreign  body,  e.g.,  a  coin,  we 
may  forthwith  attempt  to  extract  it  with  a  Grafe's  basket.  Otherwise 
we  should  employ  a  whale-bone  sound  witli  a  metal  or  ivory  top,  as 
a  third  instrument,  in  order  to  determine  the  nature  of  the  foreign 
body  by  the  sensation  experienced  when  the  sound  impinges  upon  it. 
But  if  the  sound  encounters  no  obstruction,  we  cannot  exclude  a 
foreign  body,  for  even  an  artificial  plate  may  be  passed  by  the 
instrument  without  detecting  it.  But  if  the  sound,  especially  the 
sponge  sound,  brings  up  blood  when  carefully  passed,  there  is  always 
a  suspicion  of  a  foreign  body,  and  if  pus  is  brought  up  it  becomes 
very  probable. 

In  all  cases,  but  especially  in  doubtful  ones,  Rontgen  rays  should 


126 


SURGICAL   DISEASES   OF   THE    NECK 


be  employed,  or  a  skiagram  taken.  Coins  appear  most  distinctly 
(fig.  64),  but  in  a  successful  picture,  pieces  of  bone,  teeth,  and  the 
metal  portion  of  dentures  may  be  visible.  As  a  last  resource,  the 
expert  may  proceed  to  use  the  oesophagoscope,  which  will  provide 
the  truest  solution.  This  instrument  is  naturally  not  one  often  used  by 
general  practitioners,  and  therefore  must  be  entrusted  to  the  expert. 
Matters  are,  however,  not  concluded  with  the  diagnosis  of  a  foreign 

body.  Treatment  and 
prognosis  demand 
some  information  as 
to  the  presence  of 
an  injury  to  the  oeso- 
phagus, or  of  a  pres- 
sure ulcer  with  an 
incipient  peri -oeso- 
phageal phlegmon. 
In  these  circum- 
stances the  attempts 
at  extraction  must  be 
most  carefully  con- 
ducted, the  prognosis 
must  be  ^  guarded, 
and  the  patient 
must  be  attentively 
watched,  even  after 
the  successful  re- 
moval of  the  foreign 
body.  In  order  that 
we  should  not  be 
blamed  for  symptoms 
which  already  exist, 
we  must  take  the 
temperature  and 
pulse  before  the  ex- 
traction ;  and  if  the 
foreign  body  is  in  the  upper  portion  of  the  oesophagus,  we  must  note 
whether  severe  pain  on  pressure,  swelling  and  oedema  in  the  neck,, 
point  to  the  existence  of  a  peri-cesophageal  phlegmon. 

It  seems  incredible  that  a  foreign  body  may  lodge  in  the  oeso- 
phagus for  quite  a  long  time  without  causing  severe  symptoms.  In 
the  case  illustrated  in  fig.  64,  the  copper  coin  had  been  in  the  oeso- 
phagus for  three  weeks,  and  there  was  such  an  absence  of  symptoms- 
that  both  the  doctor  and  the  mother  doubted  its  presence  before  the 
skiagram  was  taken. 


Fig.  64. — Copper  coin  in  ihe  oesophagus  (for  three  weeks) 


DIFFICULTY    IX    SWALLOWING  12'/ 

Besides  foreign  bodies,  the  causes  for  acute  onset  of  difficulty  in 
deglutition  include  corrosion  by  alkalis  or  acids,  compression  by  an 
aciilc  tJiyroiciitis,  acntc  goitrons  infianiniation,  or  a  phlegmon  of  flic  neck 
or  mediastiiinm. 

An  accurate  history  is  usually  available  in  cases  of  corrosion, 
except  in  children,  hysterical  individuals,  and  pronounced  mental 
patients.  The  very  severe  initial  symptoms  generally  abate,  but  in 
the  course  of  three  or  four  weeks  they  are  replaced  by  a  gradually 
increasing  stricture.  In  these  cases  great  significance  attaches  to  the 
persistent  regurgitation  or  vomiting  of  blood-stained  fluid. 

Inflammatory  processes  in  the  neck  are  at  once  recognized  by 
appearance  and  by  palpation,  and  a  mediastinal  phlegmon,  inde- 
pendent of  a  foreign  body  or  cancerous  disease  of  the  gullet  or 
bronchi,  is  a  very  great  rarity. 

If  the  difficul'y  in  swallowing  has  come  on  gradually,  the  cause 
may  be  a  narrowing  of  the  oesophagus,  or  external  pressure 
thereon,  or  a  functional  disturbance.  The  first  occurs  in  cancer 
and  cicatricial  stricture  after  ulcers — mostly  due  to  corrosion  or 
svphilis  ;  and  external  pressure  results  from  tumours  of  the  neck, 
changes  in  the  shape  of  the  spinal  column,  aneurisms,  mediastinal 
tumours  of  any  kind,  cold  abscesses,  and  diverticula  of  the 
oesophagus. 

Before  we  proceed  to  use  the  sound,  there  are  others  matters  to 
note,  because  the  instrument  is  not  always  safe,  and  because,  not  all 
patients  are  equally  agreeable  to  its  employment.  We  must,  above  all, 
be  able  to  exclude  aneurism.  For  this  purpose,  it  is  necessary  to  begin 
by  the  percussion  and  auscultation  of  the  thoracic  organs,  and  bv 
examining  for  other  signs  of  aneurism.  If  they  ai"e  present,  we  should 
take  care  not  to  pass  a  sound.  If  examination  reveals  some  malignant 
condition,  the  introduction  of  a  sound  can  yield  no  fresh  information. 

It  is  necessary  to  note  the  precise  characteristics  of  the  difftcnltv  in 
sivalloiving,  because  they  point  sometimes  to  the  nature  and  situation 
of  the  obstruction.  If  the  patient  complains,  in  the  earlv  stage  of  his 
disease,  of  a  constant  expectoration  of  saliva,  we  must  conclude  that 
the  obstruction  is  situated  high  up,  so  that  the  gullet  cannot  dilate 
above  it.  We  must  come  to  the  same  conclusion,  if  a  constant  desire 
to  swallow  is  the  first  symptom.  But  if  the  patient  states  that  as  soon 
as  he  takes  a  cup  of  tea  or  milk  he  forthwith  vomits  it,  but  that  the 
vomit  is  not  sour,  that  he  frequently  vomits  insipid  mucoid  material 
l:)etween  meals,  we  may  suspect  the  case  is  not  one  of  genuine 
vomiting,  but  merely  of  the  evacuation  of  the  spindle-shaped  oeso- 
phageal dilatation  which  always  forms  above  a  deep-seated  obstruc- 
tion. This  profuse  regurgitation  shows  that  the  obstruction  is  deeply 
situated  and  that   it  is  of    some  considerable  duration.     These  cases 


128  SURGICAL   DISEASES    OF   THE   XECK 

have  often  been  treated  for  months  as  gastric  disorders.  If  we 
ascertain  that  the  act  of  swallowing  has  gradual!}'  become  difficult, 
that  at  first,  solid  food  well  masticated  and  mixed  with  water  went 
down,  but  that  latterly  only  liquids  can  be  taken  ;  if  there  is  neither 
the  constant  desire  to  swallow,  nor  the  profuse  regurgitation  of  liquids 
just  drunk,  we  should  think  of  a  gradually  developing  stenosis  in  the 
middle  of  the  oesophagus.  A  glass  of  water  will  aflford  the  oppor- 
tunity of  a  test.  If  the  patient  begins  to  cough  after  the  first  or 
second  draught,  the  obstruction  is  high  up.  But  if  he  can  quickly  drink 
a  half  or  the  whole  of  the  glass  before  it  returns,  the  obstruction 
must  be  near  the  cardiac  end  ;  the  more  water  that  can  be  swallowed 
the  lower  it  is.  The  neck  of  the  patient  must  be  inspected  during  this 
procedure.  If  hard  glands  exist  above  the  clavicle,  and  the  patient 
complains  of  pains  in  the  shoulder  and  back  of  the  neck,  there  can  be 
no  doubt  about  the  diagnosis  of  cancer.  If  one  side  of  the  neck  fills 
up  somewhat  during  the  swallowing,  we  should  think  of  a  direiiicnlmn. 

Having  proceeded  thus  far  with  our  examination  we  mav  now^ 
resort  to  the  sound,  provided  that  we  have  excluded  an  aneurism.  By 
means  of  the  sound  we  can  distinguish  between  a  true  stricture  and  a 
stenosis  produced  by  compression,  just  as  we  can  distinguish  a 
stricture  of  the  urethra  from  hypertrophy  of  the  prostrate.  If,  despite 
difficultv  in  swallowing,  a  medium  sized  or  larger  sound  immediately 
passes  into  the  stomach  at  each  attempt,  the  case  is  one  of  a  tumour 
compressing  the  gullet  from  without.  If  the  sound  is  at  one  time 
arrested  at  a  short  distance,  whereas  at  another  time  it  passes  easily, 
there  can  be  no  question  about  the  diagnosis  of  a  diverticulum, 
provided  that  the  instrument  has  not  been  held  up  by  a  fungating 
projecting  carcinoma  which  has  not  yet  led  to  stricture.  The  presence 
of  this  last  condition  w^ould  be  recognized  by  slight  bleeding.  If  the 
neck  becomes  inflated  on  swallowing  and  this  swollen  part  can  be 
emptied  on  pressure,  the  diagnosis  of  diverticulum  is  conBrmed,  and 
it  is  superfluous  to  render  the  stricture  visible  by  filling  with  bismuth 
and  applying  the  Rontgen-rays. 

The  question  whether  a  case  is  to  be  grouped  under  prcssnrc  or 
traction  divert icnia  is  easily  settled.  The  former  alone,  when  full, 
cause  blocking  of  the  uppej-  part  of  the  gullet,  and  produce  clinical 
symptoms.  They  are  usually  situated  in  the  cervical  portion  of  the 
oesophagus  and  only  exceptionally  in  the  thoracic  portion.  The 
latter,  when  they  are  large  enough,  cause  the  usual  symptoms  of 
diverticula,  even  swelling  up  to  the  neck.  Absolute  accuracy  of 
diagnosis  can  only  be  assured  by  Rontgen-rays.  Traction  diverticula 
are  usually  discovered  post-mortem,  and  the  sound  has  no  special 
tendency  to  catch  in  them.  They  hardly  enter  at  all  into  clinical 
consideration.     Traction   diverticula  seldom  dilate  through  pressure. 

Spindle-shaped    dilatation    of   the  oesophagus,   previously  noted. 


DIFFICULTY    IN    SWALLOWING  I29 

and    dependent    upon     some    functional    disturbance    must    not    be 
confused  with  a  diverticulum. 

It  is  certain  that  this  condition  may  sometimes  be  caused  by  spasm 
of  the  cardiac  end  of  stomach  ;  but  the  possibility  of  it  being  caused 
in  consequence  of  paralysis  of  the  oesophageal  muscle  cannot  be 
excluded.  Solid  food  may  remain  in  the  oesophagus  for  days  at  a 
time.  The  sound  can  be  moved  about  in  the  oesophagus  remarkably 
easily,  and  it  occasionally  catches  in  its  wall,  so  that  a  diverticulum 
would  suggest  itself,  if  it  were  not  so  deeply  situated.  The  emaciation 
is  often  very  pronounced,  but  even  after  many  years'  duration,  it  does 
not  reach  the  extreme  degree  which  is  usually  present  after  one  year's 
suffering  from  cancer  of  the  oesophagus.  As  in  the  case  of  a  diver- 
ticulum, the  presence  of  this  dilatation  can  be  demonstrated  by  the 
Rontgen-rays  after  a  bismuth  meal. 

If  the  oesophagus  is  not  permeable  to  a  soft  sound  of  medium 
thickness  (10  mm.),  we  should  endeavour  to  pass  an  olivary  sound, 
beginning  with  one  of  a  somewhat  smaller  calibre,  but  not  the 
smallest,  because  this  is  much  more  liable  to  penetrate  a  putrefying 
growth  than  a  thicker  one. 

Having  overcome  the  first  difficulty,  the  cricoid  cartilage  at  a 
distance  of  15  cm.  (6  inches)  from  the  upper  incisors,  the  sound  passes 
along  easily  until  the  stenosis  is  encountered.  If  delay  arises  here, 
the  sound  is  withdrawn  somewhat  and  then  pushed  on  again,  in  case 
it  may  have  caught  against  some  projection  of  the  new  growth.  But 
if  this  manoeuvre  does  not  succeed  in  passing  the  sound  further  on, 
without  violence,  we  must  try  smaller  sounds  until  we  hit  upon  the  one 
which  just  goes  through.  The  sound  is  pushed  right  on  into  the 
stomach  to  see  whether  there  is  only  one  obstruction,  and  in  with- 
drawing the  instrument  we  note  the  exact  spot  where  it  is  grasped  so  as 
to  determine  the  lower  limit  of  the  obstruction. 

This  point  is  sometimes  of  practical  importance,  because  carcino- 
mata,  whose  lower  limit  is  not  more  than  20  cm.  (8  m.)  from  the 
incisors,  can  be  removed  through  the  neck. 

It  is  obvious  that  a  physiological  obstruction  must  not  be  mistaken 
for  a  pathological  one  ;  the  cricoid  cartilage,  situated  15  cm.  from  the 
upper  incisors  has  already  been  mentioned.  A  little  resilience  is  also 
felt  at  the  level  of  the  bifurcation  of  the  trachea  (26-27  cm.),  and  this 
is  a  little  more  pronounced  when  the  sound  passes  through  the 
oesophageal  opening  in  the  diaphragm  (38  cm.)  We  must  not  be 
deceived  by  spastic  constriction  which  occurs  now  and  again  in 
nervous  individuals,  and  which  may  prevent  the  passage  of  tiie  sound, 
analogous  to  the  case  of  urethral  spasm.  We  should  conclude  that 
this  kind  of  difficulty  is  present  if  the  condition  varies  from  time  to 
time  while  genuine  signs  of  diverticula  are  absent. 

If  we  have  found  a  stricture,  we  must  next  decide  whether  it  is 
cancerous  or  cicatricial.      A    patient    never    forgets    having    drunk    a 


130  SURGICAL   DISEASES   OF  THE   NECK 

corrosive  acid  or  alkali,  and  therefore  the  evidence  for  a  stricture  from 
corrosion  is  at  once  available ;  so  that  in  practice  the  diagnostic 
distinction  usually  concerns  cancerous  and  syphilitic  stricture.  A 
recently  developed  hard  gland  in  the  supraclavicular  region  points  to 
cancer. 

There  is  no  connection  between  the  size  and  age  of  the  cancer 
and  the  extent  of  the  grandular  enlargement.  I  have  seen  a  bunch  of 
glands  as  large  as  a  tist,  when  there  was  clinically  nothing  at  all 
definite,  the  autopsy  only  revealing  a  growth  of  2  cm.,  which  had  not 
formed  a  ring,  but  allowed  even  the  largest  sound  to  pass.  On  the 
other  hand  it  is  often  impossible  to  feel  any  enlargement  of  the  supra- 
clavicular glands,  although  the  cancer  be  of  great  extent. 

Age,  addiction  to  tobacco  or  alcohol  only  afford  approximate  in- 
dications. But  a  history  of  old  syphilis,  and  especially  the  presence 
of  other  tertiary  signs,  is  of  great  significance,  when  enlarged  glands 
are  absent. 

The  course  of  the  disease  is  conclusive  from  the  clinical  stand- 
point. A  syphilitic  stricture  may  develop  more  quickly  than  cancer, 
but  once  having  formed,  it  does  not  increase  continuously  like  a 
cancerous  stricture.  Neither  is  syphilitic  stricture  attended  by  the 
spontaneous  pain  which  is  seldom  absent  in  advancing  cancer. 

The  diagnosis  may  be  confirmed  by  oesophagoscopy,  by  aid  of 
which  a  piece  of  the  tissue  in  question  can  be  removed  for  examina- 
tion. But  cancerous  stricture  is  so  much  more  frequent  than  syphilitic 
stricture,  that  we  may  well  dispense  with  this  method.  A  man  of 
advancing  years,  suffering  from  a  gradnallv  increasing  stricture  of  tlie 
oesophagus  is  in  all  frobabilitv  a  victim  of  carcinoma. 

In  addition  to  syphilis  and  the  action  of  corrosives,  certain  other 
rare  causes  of  stricture  have  been  noted,  viz.,  non-traumatic  ulcers, 
peptic  ulcers  of  the  lower  part  of  the  oesophagus  and  peri-oesophageal 
abscesses. 

Sarcoma  of  the  oesophagus  is  very  rare,  and  can  only  be  diagnosed 
with  the  microscooe. 


CHAPTER   XXII. 
ABSCESSES   OF   THE   NECK. 

The  questions  involved  in  acute  abscesses  and  acute  phlegmons  of 
the  neck  are  so  different  from  those  which  present  themselves  in 
chronic  abscesses,  that  we  separate  the  two  classes,  although  inter- 
mediate forms  do  occur. 


ABSCESSES    OF   THE    NECK  T3I 

,4.— ACUTE    INFLAMMATORY    PROCESSES. 

In  cases  of  phlegmon  or  abscess  of  the  neck,  our  first  concern  is  to 
ascertam  the  position  of  the  inflammation.  If  the  latter  corresponds 
to  the  known  situation  of  glands,  we  shall  not  be  wrong  in  assuming 
that  there  is  suppuration  of  the  glands.  This  diagnosis  is  confirmed 
by  daily  experience,  but  our  task  is  not  completed  therewith.  Glands 
do  not  suppurate  of  themselves  ;  there  must  be  some  antecedent  in- 
fection from  without,  and  the  suppuration  represents  the  attempt  of 
the  glands  to  prevent  the  micro-organisms  gaining  further  access  into 
the  system.  We  must,  therefore,  search  for  the  portal  of  entry.  If  the 
sub-mental  or  sub-maxillary  glands,  or  those  along  the  large  vessels 
are  involved,  there  may  be  some  easily  visible  skin  infection  such  as 
a  furuncle,  but  the  origin  is  more  probably  in  the  mouth  or  pharynx, 
especially  in  connection  with  the  gums,  teeth,  or  tonsils.  This  kind 
of  cervical  abscess  is  most  prevalent  after  scarlet  fever  and  diphtheria. 
Sometimes  the  inflammation  at  the  portal  of  entry  is  so  slight  that 
the  most  careful  examination  is  required  to  detect  it.  If  the  glands 
at  the  back  of  the  neck  are  suppurating,  a  condition  to  which  children 
are  prone,  the  experienced  practitioner  will  at  once  look  for  an  eczema 
of  the  scalp,  and  he  will  rarely  be  disappointed. 

We  will  now  discuss  the  various  regions  of  the  neck. 


(1)  THE  SUB-MENTAL  REGION. 

Sub-mental  abscesses  are  easy  to  recognize,  for  they  almost  always 
arise  from  the  Ivinphatlc  glands  and  not  merely  from  the  jaw.  The  portal 
of  entry  for  the  infection  is  usually  situated  on  the  under  lip  or  chin. 
A  persistent  abscess  in  this  neighbourhood,  which  fails  to  heal  after 
incision,  must  be  regarded  as  a  snppnrating  dermoid  of  the  floor  of  the 
mouth,  although  these  usually  grow  towards  the  mouth.  The  sub- 
lingual gland  very  rarely  comes  into  question,  and  it  is  so  situated 
that  if  it  does  inflame  the  swelling  is  inwards. 

In  acute  glossitis  and  in  cellulitis  of  the  floor  of  the  mouth  there 
is  also  oedematous  swelling  of  the  sub-mental  region. 

(2)  THE  SUB-MAXILLARY  REGION. 

Acute  inflammatory  swellings  of  the  sub-maxillary  region  may  be 
due  to  one  of  the  following  causes  : — ■ 

{a)  Periostitis  op  the  jaiv  after  caries  of  the  teeth.  Examination  of 
the  teeth  and  gums,  palpation  of  the  jaw  will  indicate  the  existence 
and  situation  of  the  inflammation. 

(6)  Osteo-niyelitis  of  the  jaw.      This   dift'ers  from  periostitis  by  its 


132  SURGICAL    DISEASES    OF   THE    NECK 

great  extent  (usually  bi-lateral)  and  the  greater  severity  of  the  general 
symptoms. 

(c)  Acute  inffamuiatioii  of  the  sub-maxitlary  gland  (salivary),  through 
obstruction  of  Wharton's  duct  (salivary  calculus),  infection  from  the 
mouth,  or  as  part  of  an  epidemic  parotitis.  The  gland  can  be  more 
or  less  easily  felt,  both  in  the  mouth  and  externally.  Sometimes  pus 
exudes  from  Wharton's  duct  when  pressure  is  made  on  the  tumour. 
The  occurrence  of  repeated  attacks  suggests  calculus,  which  can 
occasionally  be  felt  within  the  mouth,  especially  after  its  exact  position 
has  been  ascertained  by  a  skiagram.  If  the  parotitis  is  predominant, 
there  is  no  difficulty  about  the  diagnosis. 

(d)  Inflammation  of  the  lymphatic  gland  tissue  enclosed  in  the 
capsule  of  the  salivary  glands,  so  called  angina  liidovici.  Here  also, 
the  swelling  projects  mainly  into  the  mouth,  but  the  general  symptoms 
of  infection  are  much  more  severe  than  in  inflammation  of  the  salivary 
glands,  and  there  is  in  addition  a  very  widespread  oedema. 

(f)  Inflammation  of  the  superficial  lymphatic  glands  superjacent  to 
the  salivary  glands.  This  is  the  most  frequent  form  of  sub-maxillary 
phlegmon,  and  chiefly  spreads  outwards.  It  causes  fluctuation  much 
more  quickly  than  intra-capsular  suppuration,  and  is  less  dangerous. 
The  infection  may  start  from  the  nose,  eye,  cheek,  or  gums. 

A  laryngeal  perichondritis  may  open  externally  in  this  direction, 
and  suppurative  periostitis  of  tJie  hvoid  bone  may  be  mentioned  as  a 
curiosity. 


(3)  THE  SIDE  OF  THE  NECK. 

Practically  the  only  condition  which  presents  itself  at  the  side  of 
the  neck,  in  the  sterno-mastoid  region,  is  glandnlar  abscess.  If  no 
focus  of  infection  is  found  on  the  skin  or  mucous  membrane,  we 
must  assume  that  the  original  disease,  eczema  of  the  head,  rhagades 
on  the  nose,  and  inflammation  of  the  gums,  &c.,  had  already  recovered 
when  the  abscess  came  on.  Injury  to  the  mucous  membrane  of  the 
pharynx  or  gullet  by  a  fish-bone  or  similar  pointed  foreign  body  is 
a  rarer  cause  of  cervical  abscess.  Abscesses  tracking  from  the 
cesophagns  always  appear  first  in  the  neighbourhood  of  the  sterno- 
mastoid,  and  are  recognized  by  the  fact  that  they  cause  pain  on 
swallowing  from  the  very  beginning.  The  patient  will  also,  as  a 
rule,  be  able  to  recall  the  severe  sudden  pain  caused  by  the  foreign 
body  responsible  for  the  mischief.  Pain  on  deep  pressure  can  usually 
be  elicited  before  any  inflammatory  change  appears  on  the  skin  ;  and 
the  abscess  does  not  reach  the  surface  in  the  form  of  a  circumscribed 
swelling  but  as  a  diffuse  phlegmon. 


ABSCESSES    OF   THE    NECK  I33 

(4)   SUPRA-CLAVICULAR    REGION. 

Abscesses  and  phlegmons  in  the  supra-clavicular  fossa  are  less 
frequent.  The  glands  in  this  position  very  rarely  suppurate,  because 
the  infective  organisms  are  usually  arrested  by  glands  higher  up. 
The  abscesses  which  do  occur  in  this  region  are  usually  due  to 
extension  of  suppuration  from  above.  If  a  phlegmon  does  arise 
primarily  in  the  supra-clavicular  fossa,  we  must  think  of  osfeo-iuyclitls 
of  the  clavicle'. 

(5)  ANTERIOR   TRIANGLE  OF   THE    NECK. 

We  now  proceed  to  the  somewhat  rare  abscesses  of  the  anterior 
triangle  of  the  neck.  They  usually  originate  in  the  thyroid  gland, 
whether  the  change  therein  is  only  goitrous  or  not.  If  the  patient  is 
seen  in  an  early  stage  when  the  inflammatory  process  is  limited  to  the 
thyroid  gland  or  to  a  goitre,  there  is  no  difficulty  in  the  diagnosis. 
But  if  the  patient  is  not  seen  until  a  state  of  diffuse  phlegmon  has 
supervened,  it  may  be  necessary  to  consider  the  possibility  of  myositis 
of  the  stenio-inastoid.  Osteo-inyelitis  of  the  mannbriinn  sterni  with  the 
pus  tracking  upwards,  might  also  be  mistaken  for  inflammation  of  the 
thyroid  gland  ;  but  the  pain  on  pressure  over  the  sternum  should 
guide  us  to  a  correct  diagnosis. 

Finally,  there  are  phlegmons  of  the  anterior  mediastinum  wdiich 
appears  in  the  neck.  I  have  seen  two  cases  which  ended  fatally, 
despite  early  incision. 

(6)   POSTERIOR  CERVICAL  REGION. 

Abscesses  in  the  posterior  cervical  region  and  its  neighbourhood 
are  more  frequent.  If  the  abscess  is  situated  posteriorly,  beloiv  the 
mastoid  process,  and  has  been  preceded  by  middle-ear  symptoms,  we 
cannot  fail  to  diagnose  a  Bezold's  abscess,  i.e.,  an  abscess  of  the  mastoid 
process  which  has  burst  into  the  neck. 

How  can  this  latter  variety  of  abscess  be  distinguished  from  one 
of  the  ordinary  superficial  glandular  abscesses  of  this  region  ?  An 
abscess  starting  from  the  petrous  bone,  or  mastoid  process  is  at  first 
deeply  situated  and  covered  by  the  insertion  of  the  sterno-mastoid. 
The  patient  therefore  complains  of  pain  and  holds  his  head  stiff,  before 
any  swelling  or  redness  of  the  skin  appears.  But  on  the  other  hand, 
glandular  abscesses  are  from  the  first  quite  close  to  the  skin  ;  the 
subjective  disturbances,  therefore,  go  hand  in  hand  with  the  visible  and 
palpable  development  of  the  abscess. 

A  carbuncle  at  the  back  of  the  neck  presents  a  very  distinctive 
picture.  The  simple  posterior  cervical  furuncle  demands  no  dia- 
gnostic skill ;    and  it  is  not  easy  to  mistake  a  cai-buncle  formed  by  the 


134  SURGICAL    DISEASES    OF   THE    NECK 

agglomeration  of  a  group  of  contiguous  furuncles — sometimes  called 
anthrax,  after  its  French  designation. 

Both  terms  occasionally  mislead  the  beginner  into  thinking  of  true 
anthrax.  Before  the  advent  of  bacteriology  the  differential  diagnosis 
was  often  difficult.  As  a  matter  of  fact  the  typical  carbuncle  at  the 
back  of  the  neck  has  nothing  to  do  with  anthrax.  It  is  a  staphylo- 
mycosis which  finds  a  favourite  soil  for  growth  in  the  aged  or  diabetic. 

The  inflammatory  process  is  not  always  limited  to  the  diseased 
hair  follicles  and  their  immediate  vicinity.  The  entire  integument  of 
the  back  of  the  neck,  from  ear  to  ear,  may  become  indurated  and 
of  a  bluish  red  colour.  The  persistence  of  fever  after  the  evacua- 
tion of  cores  of  pus  shows  that  some  deep  inflammation  exists. 
A  phlegmon  may  develop  over  a  muscle,  beneath  superficial  skin 
which  is  perforated  like  a  sieve,  but  the  cutaneous  infiltration  renders 
the  detection  of  fluctuation  very  difficult.  Nevertheless,  it  is  important 
to  open  such  a  phlegmon  as  quickly  as  possible,  in  order  to  anticipate 
the  deep  extension  of  the  pus. 

If  there  is  no  furuncle  to  explain  the  condition,  disease  of  the  bone 
must  be  thought  of,  i.e.,  osieo-inyelitis  of  the  occipital  bone,  which  is  more 
likely  to  be  metastatic  than  primary. 

Suppuration  of  a  tuuiour  at  tlie  tjack  of  tJie  iiecli  is  rarer  still.  While 
acting  as  assistant,  I  saw  a  girl  with  a  large  fistulous  abscess  at  the 
back  of  the  neck  constantly  discharging  fcetid  pus.  It  was  a  case  of 
a  dennoid,  containing  a  large  bunch  of  hair.  Lipoumta  may  also 
suppurate,  exceptionally. 


/i.— CHRONIC  ABSCESSES. 

A  slowly  developing,  painless  and  circumscribed  swelling  at  the 
back  of  the  neck  should  suggest  a  new  growth,  and  this  diagnosis 
should  only  be  abandoned  in  favour  of  a  tubercular  or  cold  abscess 
if  all  the  cnxamstances  are  not  in  accord  with  it.  The  possibility  of 
cold  abscess  has  occasionally  been  forgotten,  and  immediate  operation 
has  been  undertaken  in  the  expectation  of  finding  a  tumour  or  a  cyst. 
This  error  is  easily  avoided  if  the  glands  are  suppurating,  because  the 
multiplicity  of  the  swellings  will  indicate,  even  to  the  beginner,  that 
glandular  disease  is  present.  But  it  is  quite  otherwise  when  a  deep- 
lying  abscess  starts  from  a  tubercular  vertebra.  If  it  has  not  vet  reached 
the  surface,  the  presence  of  fluctuation  cannot  always  be  detected,  and 
the  original  specific  disease  may  not  have  manifested  itself  in  any 
striking  manner.  There  is,  however,  even  in  this  early  stage,  a  sym- 
ptom very  significant  of  tubercular  abscess,  and  that  is,  the  situation 
of  the  swelling  beliiud  the  thyroid  and  beliiud  the  carotid,  to  which 
further  reference  will  be  made  in  discussing  tumours  of  the  neck. 
A  swelling  which  pushes  the  carotid  artery  forward  must  be  a  tumour 


ABSCESSES    OF   THE    NECK 


135 


of  the  vertebral  column,   or  of  the  deep  cervical  muscles,  or  a  cold 
abscess. 

If  the  pus  has  tracked  to  the  surface  bv  one  route  between  the 
muscles,  the  deep  origin  of  the  abscess  may  be  obscured.  It  is  there- 
fore always  necessary  to  examine  the  inside  of  the  throat,  because  the 
origin  of  the  abscess  may  be  easier  to  detect  from  there  than  from  the 
surface  of  the  neck. 

A  careful   examination   of  the  spine  will  generally  reveal  signs  of 
tubercular    disease   before   the    patient   is    conscious  of   any.  trouble. 
The  experienced  eye  will  also 
note  the  stiffness  of  the  neck,      - 
and  will  be  struck  by  the  fact 
that  the  patient  never  turns  his 
head  without  turning  his  back 
at  the  same  time. 

A  full  cvsopluigeal  divcrticu- 
liini  projecting  into  the  side 
of  the  neck  may  feel  like  a 
chronic  abscess.  But  its  long 
duration,  extending  over  years, 
and  its  objective  condition  of 
expressibility  render  the  dia- 
gnosis quite  easy. 

Not  all  chronic  abscesses 
of  the  neck  are  tubercular. 
These  are  always  distinguished 
by  their  softness,  but  there 
are  some  clironic  abscesses 
in  the  neck  which  are,  on  the 
contrary,  remarkably  hard. 
Reclus  applied  to  them  the 
term  "  phlegmon  ligneux," 
and  in  German  the  expression 
"  holzphlegmone  "  (board- 
like phlegmon)  has  been 
adopted.  Actinomycosis,  which 

we  have  already  discussed,  is  one  example  of  the  cases  which  must 
be  ascribed  to  this  group.  The  occurrence  of  small  soft  areas  in 
the  midst  of  the  board-like  induration  allows  us  to  recognize  actino- 
mycosis before  the  characteristic  granules  have  been  discovered. 

Cases  of  hard  chronic  inflammation,  which  are  not  to  be  attributed 
to  the  ray-fungus,  have  been  found  to  be  due  to  various  schizomycetes. 
The  patients  are  always  in  a  feeble  state  of  general  health  and  of  an 
advanced  age.  The  board-like  nature  of  a  phelgmon  does  not,  there- 
fore, represent  any  specific  disease  ;  it  is  merely  the  distinctive  reaction 


_  Fig.  65. — Tubercular  abscess  from  spinal 
disease.  Upper  half  of  sterno-mastoid  bulged 
forward. 


136  SURGICAL   DISEASES   OF   THE   NECK 

evinced  by  old  cachectic  individuals  towards  the  presence  of  any 
kind  of  suppuration.  Instead  of  the  abscess  breaking,  it  becomes 
surrounded  by  an  induration  of  connective  tissue,  which  renders  it 
all  the  more  difficult  either  to  get  absorbed  or  to  burst  through. 
Thus  it  is  that  the  whole  process  is  so  protracted. 

Finally,  it  should  be  noted  that  these  "  board-like  phlegmons  "  must 
not  be  confused  with  Ludwig's  angina,  a  mistake  which  has  occurred, 
owing  to  their  hardness  on  palpation.  Notwithstanding  the  term 
"  phlegmons,"  these  cases  are  of  a  definitely  chronic  character,  whereas 
Ludwig's  angina  is  characterized  by  its  acuteness.  These  cases  have 
also  often  been  mistaken  for  malignant  growths,  a  matter  to  which  we 
will  refer  subsequently. 


CHAPTER    XXIII. 
SINUSES  IN  THE  NECK. 


SixuSES  which  result  from  iii/itries  offer  no  diagnostic  difficulties. 
The  memory  of  the  injury  abides  with  the  patient,  and  the  direction 
of  the  sinus  can  be  inferred  by  noting  whether  air  bubbles  through 
it,  whether  food  issues  from  it  or  pure  saliva  flows  therefrom.  All 
other  sinuses  arise  either  from  inflammatory  processes  (tubercle, 
syphilis,  actinomycosis),  or  from    congenital  anomalies. 

A  correct  diagnosis  can  usually  be  made  from  the  mode  of  origin, 
conrse,  and  external  appearance. 

Gummatous  inflammation  does  not  lead  to  sinus  formation, 
unless  there  be  extensive  destruction  round  about,  and  such  a  sinus 
does  not  persist  very  long,  if  no  deeply  situated  organ  has  been 
perforated.  The  sinuses  which  are  present  in  actinomycosis  are 
situated,  as  previously  mentioned,  in  hard  board-like  tissue  ;  they  are 
not  drawn  in,  but  are  found  on  the  summits  of  small  dark-red  pro- 
jections of  soft  skin.  Their  duration  is  short,  unless  the  disease  has 
affected  deeper  organs,  such  as  the  spinal  column  and  the  base  of  tiie 
skull,  when  the  sinuses  may  last  for  months,  and  become  contracted 
while  the  characteristic  changes  of  actinomycosis  round  about  may 
become  obliterated.  In  such  cases  there  is  always  some  secondary 
infection  at  work.  Tubercular  sinuses- arise  either  from  glands  or 
from  tnhercnlar  foci  in  tnine,  generally  in  the  vertebral  column.  In 
the   former    case    their    duration    is  a   matter   of    weeks,  or   at    most 


SIXUSES    I\    THE    XECK 


137 


months,  and  there  will  usually  be  present,  among  old  scars,  some 
remaining  tubercular  glands  in  various  stages  of  suppurative  softening. 
But  sinuses  arising  from  bone,  such  as  in  spinal  caries,  mav  persist 
for  years.  Here,  however,  signs  of  tubercular  disease  in  the  spinal 
column  will  alwavs  be  present. 

The  points  already  mentioned  will  usually  enable  us  to  distinguish 
between  a  sinus  due  to  infiainination  and  one  due  to  coiigeiiittril  causes. 
The  history  will,  as  a  rule,  inform  us  whether  the  sinus  dates  from 
birth  ;  but  we  must  not  exclude  its  congenital  origin,  because  the 
sinus  first  appeared  in  later  years.  It  frequentlv  happens  that  a 
branchial-cleft  cvst  persists 
in  the  deeper  parts  for  years 
after  birth,  and  then  gradu- 
ally makes  its  way  to  the 
surface,  finally  penetrating 
the  skin  and  forming  a  sinus. 
Neither  must  we  at  once 
assume  that  a  sinus  has  an 
inflammatory  origin,  because 
signs  of  inflammation  appear 
round  about,  for  these  bran- 
chial-cleft cysts  are  often 
the  seat  of  inflammatory 
processes.  Inflammation  of 
a  cyst  alternates  with  the 
breaking  out  of  the  sinus, 
so  that  the  patient  complains 
of  an  "  abscess  in  the  neck," 
which  empties  itself  from 
time  to  time,  and  which, 
after  a  longer  or  shorter 
existence,  again  develops  a 
sinus.  The  inflammatory 
changes  in  cases  of  congen- 
ital sinus  are  of  small  extent,  and  abate  as  soon  as  the  sinus  develops. 
It  appears  as  a  small  punctiform  opening,  surrounded  by  a  somewhat 
in-drawn  area  of  skin,  either  normal  or  slightly  irritated  by  secretion. 
A  sinus  of  many  years'  duration,  with  these  characters,  is  almost 
certainly   of  congenital  origin. 

The  secretion  from  a  sinus  aft'ords  us  an  additional  diagnostic  aid. 
Pm-e  pus  escapes  from  an  inflammatory  sinus  ;  but  in  the  case  of 
actinomycosis  it  is  occasionallv  mixed  with  the  characteristic  granules. 
Congenital  sinuses  discharge  a  purely  mucoid  or  muco-purulent  fluid, 
in  which  epithelial  cells  can  be  demonstrated  as  well  as  pus  cells. 


Fig.    66. — Corgenital    sinus   of  neck,    originating 
in  the  middle  but  opening  at  the  side. 


138  SURGICAL   DISEASES    OF   THE    XECK 

The  position  of  the  sinus  also  yields  useful  indications.  Con- 
genital sinuses  are  situated  in  the  middle  line,  or  in  the  region  of 
the  sterno-mastoid,  whereas  the  sinuses  of  spinal  disease,  with  which 
they  may  easily  be  confused,  are  generally  located  much  more 
posteriorly.  But  if  all  this  does  not  suffice,  we  may  test  the  connec- 
tion between  the  sinus  and  the  oral  or  pharyngeal  cavit}^  by  injecting 
some  harmless  colouring  matter  or  a  bitter  fluid. 

Finally,  we  may  scrape  some  tissue  off  the  wall  of  the  sinus  with  a 
fine,  sharp  spoon.  If,  on  examination,  this  is  shown  to  be  pure 
granulation  tissue,  with  probably  some  tubercles,  we  are  dealing  with 
an  inflammatory  fistula  ;  if  epithelial  cells  are  found,  the  case  is  one 
of  congenital  sinus. 

Assuming  that  the  diagnosis  of  congenital  sinus  is  established, 
there  still  remain  two  questions  to  be  answered. 

(i)  Is  the  case  one  of  a  hrandiial-clcft  sinus,  or  is  it  one  of 
so-called  median  sinus,  arising  from  the  thyreo-glossal  duct  ? 

(2)  Is  the  sinus  complete  or  incomplete,  i.e.,  is  it  connected  with 
the  throat  or  not? 

The  first  question  is  answered  by  the  position  of  the  sinus.  If  it 
opens  in  the  middle  line,  and  it  runs  along  the  course  of  the  middle 
line  towards  the  hyoid  bone,  its  origin  in  the  thyreo-glossal  duct  is 
quite  certain.  If  it  opens  at  the  side,  it  is  usually  a  branchial-cleft 
sinus,  aribing  from  the  first  (very  rarelv  the  ear  region),  the  second, 
or  possibly  from  the  third,  branchial-cleft.  Confusion  may  arise  if 
a  sinus  from  the  thyreo-glossal  opens  duct  laterally  (fig.  66),  and  one 
from  a  branchial-cleft  runs  centrally,  as  sometimes  happens.  We 
must,  therefore,  note  the  course  of  the  sinus  as  well  as  the  point 
of  its  exit.  The  beginner  may  be  inclined  to  use  a  probe  in 
order  to  ascertain  the  direction  of  the  sinus,  but  this  is  as 
dangerous  as  it  is  unreliable.  It  is  very  easy  to  penetrate  the  wall 
of  the  sinus  with  the  end  of  a  fine  probe,  and  thus  infect  the 
surrounding  tissue  without  ascertaining  the  direction  of  the  sinus. 
This  must  be  determined  mainly  by  palpation,  for  the  track  of  the 
sinus  feel  like  a  firm  cord.  As  the  course  of  the  sinus  which 
originates  in  the  thyreo-glossal  duct  is  a  comparatively  superficial 
one,  we  may  be  able  to  follow  the  whole  tract  as  far  as  the  body  of 
the  hyoid  bone.  If  a  sinus  opens  in  the  centre,  and  it  is  not  possible 
to  follow  its  course  in  this  way,  we  must  assume  that  the  passage  runs 
deeply,  and  to  the  side,  that  is  to  say,  that  it  is  the  sinus  of  a  branchial- 
cleft.  If  one  has  the  opportunity  for  an  X-ray  examination,  some 
bismuth  emulsion  should  be  injected  into  the  sinus,  and  its  course 
followed  either  on  the  screen  or  in  the  skiagram. 

There  are  some  cases  wherein  the  microscope  affords  the  first 
definite  differentiation.     Sinuses  originating  in  the  thyreo-glossal  duct 


TUMOURS   AND   ALLIED   SWELLINGS    OF   THE   NECK  139 

are  generally  surrounded  by  minute  lobules  of  thyroid  gland  tissue, 
a  feature  which  is,  of  course,  absent  in  the  cases  of  sinuses  from 
genuine  branchial  clefts. 

To  determine  whether  the  sinus  is  complete,  and  reaches  as  far  as 
the  throat,  we  must  adopt  the  method  of  injection,  as  already 
observed.  In  the  case  of  a  sinus  of  the  thyreo-glossal  duct  the 
coloured  fluid  will  appear  at  the  foramen  caecum,  in  front  of  the 
epiglottis  ;  in  the  case  of  a  branchial-cleft  sinus  it  will  appear  at  the 
lateral  pharyngeal  wall. 

Finally,  there  remains  one  special  form  of  sinus,  with  its  orifice  at 
the  front  or  side  of  the  neck.  It  is  usually  situated  in  the  scar  of  an 
incision,  and  thus  shows  its  artificial  origin.  When  the  patient 
swallows,  it  rises  upwards  and  forwards  with  the  thyroid  gland,  and 
if  a  probe  is  carefully  introduced,  it  loses  itself  in  a  swelling  which 
can  be  identified  as  a  goitre.  The  case  is  therefore  one  of  a  sinus 
from  a  goitre,  originating  after  incision  of  a  goitrous  abscess.  Such 
sinuses  may  persist  for  years,  if  the  inflammation  has  developed  in  a 
cystic  goitre  with  calcified  walls.  The  sinus  can  only  be  radically 
cured  either  by  removing  the  whole  cyst  or  by  extirpating  all  the 
tissue  which  is  incapable  of  cicatrizing. 

Sometimes  towards  the  end,  cancers  of  the  month,  larynx,  or  throat 
break  through  to  the  surface,  but  this  condition  .can  hardly  be  termed 
a  sinus.  The  diagnosis  is  easily  made  by  the  appearance  of  the 
opening  on  the  skin  and  by  the  symptoms  connected  with  the 
original  diseases. 


CHAPTER    XXIV. 
TUMOURS  AND  ALLIED  SWELLINGS  OF  THE  NECK. 

As  the  neck  contains  a  variety  of  organs,  it  offers  examples  of 
tumours  of  every  kind.  In  discussing  these,  we  purposely  include 
certain  congenital  cystic  structures  as  tumours,  and  at  the  same 
tmie  embrace  chronic  inflammation  of  the  lymphatic  glands  in 
this   section. 

Before  we  ascertain  the  nature  and  point  of  origin  of  a  new 
growth,  we  must  be  quite  sure  that  we  are  really  dealing  with 
a  tumour,  even  in  the  somewhat  extended  application  of  the  term 
as  just  indicated.  There  are  morbid  conditions  in  the  neck, 
producing  pseudo-tumours  which  may  mislead  even  the  experienced. 
10 


140  SURGICAL    DISEASES    OF   THE    NECK 

Tubercular  abscesses  should  be  especially  mentioned  in  this 
connection.  These  start  from  the  vertebral  column,  gradually 
track  towards  the  surface,  and  have,  as  previously  stated,  often 
been  mistaken  for  tumours  (p.  134). 

If  we  find  a  hard,  slightly  movable  tumour  in  the  submaxillary 
region,  or  even  posteriorly  thereto,  we  must  think  of  the  hoard-like 
fihlegjjion,  of  varied  origin.  The  absence  of  fever  and  pain  on 
pressure,  its  sharp  limitation  and  sometimes  a  certain  mobility  of 
the  skin  over  it,  appear  to  point  to  a  new  growth.  Even  if  the 
skin  has  become  extensively  adherent,  the  limitation  of  the  structure 
is  so  sharp  that  it  is  difficult  to  discard  the  idea  of  a  malignant 
growth.  The  careful  consideration  of  all  possible  sources  of  infection 
will,  however,  lead  to  the  recognition  of  the  true  nature  of  the 
disease.  But  sometimes  an  exploratory  puncture  only  will  give  the 
first  clue. 

This  occurred  to  me  in  the  case  of  an  aged  female  who  had  a 
phlegmon  at  the  side  of  the  neck  which  looked  like  the  terminal 
stage  of  an  inoperable  carcinoma.  Its  explanation  was  found  in  a 
periostitis  of  the  root  of  a  molar,  which  had  run  its  course  almost 
unnoticed. 

On  another  occasion  I  had  a  case  which  seemed  to  be  a  sarcoma 
of  the  side  of  the  neck,  and  which  had  become  adherent  to  the 
skin.  It  had  been  preceded  by  symptoms  arising  from  the  cranial 
nerves.  A  trial  puncture  showed  that  the  case  was  probably  one  of 
actinomycosis  starting  in  the  sphenoidal  sinus,  and  this  was  subse- 
quently confirmed  by  autopsy. 

Tubercular  or  guniuiatous  deposits  in  muscles,  especially  in  the 
sterno-mastoid,  may  be  mistaken  for  tumour.  The  same  applies  to 
cesopJiageal  diverticula. 

We  shall  refer  to  the  diagnostic  difficulties  presented  by  inflam- 
mation of  the  salivary  glands  and  the  thyroid  gland  in  their  appro- 
priate place.  We  shall  also  subsequently  discuss  the  not  infrequent 
errors  of  diagnosis  to  which  aneurysms  and  cervical  ribs  give  rise. 

In  order  to  facilitate  the  survey  we  will  discuss  the  conditions 
topographically. 

A.— THE  ANTERIOR  TRIANGLE. 

This  triangle  and  its  lateral  vicinity  consist  of  the  space  between 
the  external  borders  of  the  sterno-mastoids  and  a  horizontal  line 
drawn  through  the  upper  border  of  the  thyroid  cartilage.  It  is  so 
dominated  by  the  thyroid  gland  that  our  first  question  in  regard  to 
any  tumour  in  this  space  must  be  to  ask  whether  it  originates  in 
this  gland  or  not.  Oiie  classical  sign  will  seldom  fail  us,  i.e.,  the 
ascent  of  the  tumour  with  the  larynx  and  trachea  on  swallowing. 
This  sign  only  becomes  indefinite  or  entirely  absent  if  the  diseased 


TUMOURS   AND    ALLIED    SWELLINGS    OF   THE    NECK 


141 


gland  is  so  firmly  adherent  to  the  adjacent  structures  that  it  actually 
prevents  the  ascent  of  the  trachea. 

Further  evidence  is  afforded  by  palpation,  because  this  demon- 
strates with  more  or  less  certainty  the  connection  of  the  tumour 
with  the  thyroid  gland.  The  relation  of  these  tumours  to  the 
sterno-mastoids  is  not  at  all  constant.  They  may  project  forwards 
between  them,  or  glide  under  them  towards  the  sides  of  the  anterior 
triangle,  or  the  muscles  may  be  spread  out  flat  over  them. 

The  most  common 
disease  of  the  thyroid 
gland,  a  tumour  in  the 
wide  significance  of  the 
term,  is  goitre. 

The  connection  be- 
tween goitre  and  the 
thyroid  gland  appears  to 
us  to-day  to  be  obvious. 
But  up  to  the  middle  of 
the  nineteenth  century 
the  terms  bronchocele 
and  air  -  goitre  (Luft- 
kropf)  prevailed  in 
German  literature,  thus 
showing  the  predomi- 
nance of  imagination 
over  observation.  At 
the  end  of  the  eigh- 
teenth century  the 
theory  was  maintained 
that  a  goitre  was  a 
hernia  of  the  air-pass- 
age, and  the  term  bron- 
chocele still  persists  in 
■  English  as  a  vestige  of 
this  error.  In  the 
Middle  Ages  and  up  to 
within  the  last  hundred 

years  there  was  a  general  confusion  between  goitre  and  lymphatic 
gland  enlargement.  A  vestige  of  this  error  still  remains  in  the  use  of 
the  term  "struma"  for  "tubercle,"  which  was  formerly  common  in 
France  and  still  is  in  vogue  in  England. 

1  have  called  a  goitre  a  tumour  in  the  "widest  sense  of  the  term," 
because  most  goitres  are  not  tumours  in  the  pathological  sense,  but 
are  processes  of  hypertrophy,  hyperplasia  and  degeneration,  often 
associated  in  striking  confusion  with  changes  which  possess  certain 
characteristics  of  tumour  formation.  The  external  appearances  of 
the  goitre  afford  some  indications  of  all  this.  However,  to  ascertain 
ivliich  variety  of  goitre  we  are  dealing  with  is  not  a  mere  whim, 
but  is  a  matter  of  therapeutic  significance. 


Fig.  67. 


-Simple  hyperplasia  of  the  thyroid  gland  ("  full 
neck  ")  in  a  chlorotic  girl. 


1-12 


SURGICAL    DISEASES    OF    THE    XECK 


(1)  THE  EXTERNAL  APPEARANCES  OF  GOITRE. 

We  have  in  the  first  place  to  distinguish  between  (a)  the  dijfnse^ 
and  {b)  the  circiiniscribed  or  nodular  goitre. 


/ 


(a)  Diffuse  Goitre. 

The  diffuse  goitre  (fig.  68)  imitates  in  considerable  measure  the 
horse-shoe  shape  of  the  normal  thyroid  gland,  and  is  of  fairly  uniform 
consistence  throughout.  If  it  feels  soft,  like  a  normal  thyroid  gland, 
and  there  are  no  accompanying  vascular  symptoms,  the  case  is  one  of 
simple    hyperplasia,    without   any  other   histological  changes,   except^ 

perhaps,   a  slight  enlarge- 
■^  ment  of  the  vesicles,   Such 

a  goitre  hardly  grows 
beyond  three  times  the 
size  of  the  normal  thy- 
roid gland.  It  usually 
occurs  in  young,  and 
especially  chlorotic,  girls 
in  the  period  of  adoles- 
cence. If  the  goitre  is 
rather  firm,  and  feels  some 
what  nodular,  the  case  is 
one  of  diffuse  colloid  goitre, 
in  which  the  vesicles  are 
greatly  dilated,  the  colloid 
material  increased,  and 
under  pressure.  If  the 
tumour  is  softly  elastic,, 
compressible,  and  has  an 
expansile  pulsation,  and 
if  on  auscultation  all 
kinds  of  blowing  mur- 
murs, appreciated  by  the  hand  as  thrills,  are  heard  over  the  large 
thyroid  vessels  as  well  as  over  the  goitre,  the  case  is  one  of  vascular 
goitre. 

It  may  be  noted  here  that  the  superior  thyroid  artery  can  easily 
be  felt  on  the  external  surface  of  the  thyroid  cartilage,  whereas  the 
inferior  thyroid  artery  retires  from  the  finger,  owing  to  its  deep 
situation.  In  examining  for  pulsation,  one  must  be  careful  not  to 
mistake  the  beating  of  the  carotid  artery  for  expansile  pulsation,  and, 
of  course,  care  must  be  taken  not  to  look  upon  a  burrowing  abscess 
beneath  a  forwardly  displaced  carotid  artery  as  a  pulsating  goitre — 
as  has  actually  occurred. 


Fig.  58.  —  Diffuse  colloid  goitre. 


TUMOURS    AND    ALLIED    SWELLIXGS    OF    THE    XECK 


143 


^ 


If  we  are  confronted  by  a  vascular  goitre,  we  should  instinctively 
look  for  the  other  symptoms  which  go  to  make  up  "  Graves's 
disease." 

If  the  whole  svmptom-complex  is  well  pronounced — a  pulsating 
goitre,  exophthalmos,  tremor,  and  tachycardia— even  the  most  in- 
experienced can  have  no  doubt  about  the  diagnosis.  The  exoph- 
thalmos, more  than  anything  else,  would  indicate  the  diagnosis  to 
him. 

If  there  be 
leisure  for  fur- 
ther diagnostic 
exercises,  a 
search  may  be 
made  for  the 
rarer  symptoms. 
As  far  as  the 
eyes  are  con- 
cerned, some 
of  these  are  due 
to  mechanical 
•causes,  and 
others  to  mus- 
cular weakness 
—  for  instance, 
the  width  of 
the  palpebral 
tissure,  the  fixitv 
of  the  lids  (Stell- 
wag),  deficient 
movement  of 
the  upper  lid 
on  looking  up- 
Avards and  down- 
wards (Grafe), 
insufficiencv  of 
convergence 
{Mobius).  Gen- 
uine ocular  paralyses,  which  are  occasionallv  met  with,  must  not  be 
confused  with  these  svmptoms. 

Is  there  anything  in  the  form  of  the  goitre  in  favour  of,  or  against, 
'Graves's  disease  ?  This  evidence  is  onlv  circumstantial.  In  Graves's 
disease  the  goitre  is  diffuse  and  vascular  (tigs.  69  and  70).  Histologically 
a  diminution  of  colloid  substance  can  be  demonstrated,  and  a  prolifera- 
tion of  epithelium.  But  any  variety  of  goitre  may  become  ''Graves's 
disease "  secondarily.  We  must  therefore  not  conclude  that  a  case 
is  not  Graves's  disease  because  the  patient  has  a  nodular  goitre. 

Easy  as  the  diagnosis  is,  when  the  classical  triad  of  symptoms  is 
present,    it    may   be    extremely    difficult    when    the    disease   runs    an 


Fig.  69. — Early  stage  of  Graves's  disease. 


144 


SURGICAL    DISEASES    OF    THE    NECK 


irregular  course.  The  clinical  picture  presented  by  the  disease  is^ 
however,  more  frequently  atypical  than  t3'pical,  and  a  large  number 
of  subordinate  varieties  have  been  described — to  the  great  confusion 
of  students,  and  even  of  experts.  If  we  rigidly  cling  to  the  view  that 
hyper-thyroidism  is  the  cause  of  most  of  the  symptoms  of  Graves's 
disease,  it  is  not  always  easy  to  distinguish  between  the  normal  and 
pathological,  because  transitory  anomalies  of  function  are  con- 
ceivable in  the  thyroid,  as  in  other  glands.  We  should  therefore 
limit  the  designation  of  Graves's  disease  to  s3'mptoms  of  hyper- 
thyroidism \\'  h  i  c  h 
remain  permanent. 

The  clinical  picture 
remains  incomplete  in 
many  cases  for  months^ 
and  even  for  years.  The 
patient  complains  of 
emaciation,  increasing 
m  u  s  c  u  1  a  r  d  e  b  i  1  i  t  y ,. 
tremors,  slight  perspir- 
ations, unexplained 
diarrhoea,  long  before 
any  exophthalmos  in- 
dicates the  diagnosis 
to  the  practitioner.  If 
such  a  patient,  when 
completely  at  repose^. 
presents  strong  pulsa- 
tion of  the  carotids,  it 
is  as  definite  an  evi- 
dence in  favour  of 
Graves's  disease  as  a 
normal  amplitude  of  the 
carotid  pulse  would  be 
against  that  diagnosis. 

The  instability  of 
the  psychical  equilib- 
rium of  the  patient  is  frequently  so  predominant  that  the  case  may  be 
treated  for  years  as  one  of  neurasthenia  or  hysteria,  until  a  careful 
examination  reveals  the  cause  of  the  nervous  disturbances.  In  other 
cases,  the  cardiac  symptoms  are  the  most  predominant,  and  the  goitre 
itself  attracts  little  attention,  as  long  as  no  other  symptoms  of  Graves's 
disease  have  appeared.  Whether  these  cases  should  be  regarded  as 
thyro-toxic  goitrous  hearts,  or  as  examples  of  the  "  forme  fruste  "  of 
Graves's  disease  is  merely  a  matter  of  terminology. 


Fig.  70. — Pronounced  Graves's  disease. 


TUMOURS   AND   ALLIED   SWELLL\GS   OF  THE   NECK 


145 


It    is    obvious    that 
^ve    must    not    confuse 
circulator}^     disturb- 
ances, which  are  caused 
b}'  the  mechanical  effect 
of    the    goitre,    with 
cardiac    disturbances, 
which     are      of     toxic 
origin.      I     admit    that 
the    distinction    is    not 
always    easy.      Finally, 
one  must  not  conclude 
that  every  case  of  prom- 
inent   eyes    is    one    of 
Graves's  disease.  Prom- 
inence   of   the  eyeballs 
may  be  a  family  pecu- 
liarity.     In     order     to 
establish    the   diagnosis 
of  Graves's  disease,  it  is 
necessary  to  show  that 
the  previous  position  of 
the   eyes    was    normal, 
for   which  purpose  we 
can     derive    assistance 
from    earlier    photo- 
graphs of  the  patient. 

The  examination  of 
the  blood  is  of  interest 
for  the  diagnosis  of 
Graves's  disease,  al- 
though this  is  rather  a 
matter  for  the  laboratory 
than  for  the  consult- 
ing room.  According 
to  Kocher  and  others, 
Graves's  disease  is 
characterized  by  a  de- 
crease in  polynuclear 
leucocytes,  an  increase 
of  lymphocytes,  large 
mononuclears,  and  eosi- 
nophiles,  and  bv  a  de- 
crease in  coaguiabilitv. 


-blG.    71. — Colloid  goitre,  mainly  of  right  side,  consisting 
of  separate  lobules. 


Pendulous  goitre. 


146 


SURGICAL    DISEASES   OF   THE   XECK 


Similar  changes  occur  in  ordinary  goitre,  and  even  in  hyper- 
tliyroidism ;  but  in  the  latter  the  coagulability  is  often  increased. 
The  interpretation  of  the  blood-picture  therefore  requires  great 
care.  Our  own  experience  seems  to  show  that  more  importance 
attaches  to  a  pronounced  increase  in  the  antitryptic  content  of  the 
blood,  but  the  demonstration  of  this  cannot  be  expected  from  the 
general  practitioner.  Nevertheless,  the  employment  of  this  test  is 
desirable  in    doubtful    cases,    because    of    the    prevailing   fashion    of 

diagnosing  "  Graves's  disease  " 
on  insufhcient  evidence.  Not 
every  goitrous  individual  who 
trembles  occasionally  is  the 
subject  of  Graves's  disease. 

Recent  researches  have 
shown  that  certain  relations 
exist  between  Graves's  disease 
and  changes  in  the  thymus  ; 
but  no  useful  assistance  from 
the  point  of  view  of  diagnosis 
has  hitherto  followed  there- 
from. Still  less  has  this  fol- 
lowed from  the  more  or  less 
hypothetical  relations  which 
have  been  stated  to  exist 
between  the  thyroid  and 
other  glands,  with  internal 
and  external  secretions. 

If  an  elderly  person  is 
suffering  from  symptoms  of 
Graves's  disease,  we  should 
always  inquire  whether 
iodine  has  been  taken.  The 
rapid   disappearance  of  goi- 

\'  trous  tissue  after  iodine  treat- 

^s  ment  leads  to  a  flooding  of 

-  ^-^ '       the  system  with  thyroid  gland 

Fig.  73.— Cystic  goitre.  products,    which    manifest 

themselves,  especially  in  old 
people,  by  symptoms  of  Graves's  disease,  persisting  for  months. 


(bj  Circumscribed  Goitre. 

In  the  circumscribed  goitrous  degeneration  of  the  thyroid  gland, 
nodular  goitre,  the  entire  parenchyma  is  more  or  less  damaged — at 
any  rate  histologically — but  the  appreciable  changes  are  limited  to  a 
few  places  which  grow  into  nodules.  These  nodules  are  at  hrst 
composed  partially  of  tissue  rich  in  colloid  material,  and  partially  of 
hyperplastic  and  adenomatous-like  proliferation  ;  they  may  secondarily 
liquefy  and  become  cysts. 


TUMOURS   AND   ALLIED   SWELLINGS    OF   THE   XECK  147 


Fig.  74. — Sunken  goitre  with  relaxed  sterno-mastoids. 


Fig.  75. — Sunken  goitre  pressed  deep  down  by  contraction  of  sterno-mastoid. 


148  SURGICAL   DISEASES   OF   THE    NECK 

The  cysts  which  arise  from  dilatation  of  individual  vesicles  (giant 
vesicles)  have  no  clinical  significance. 

Frequently  there  is  only  one  nodule — when  it  is  of  an  extensive 
size.  In  other  cases,  especially  in  elderly  people,  there  is  a  whole 
bunch  of  goitrous  nodules  in  the  thyroid  gland,  one  exceeding 
another  in  circumference.  If  a  nodule  is  regular  in  form,  smooth 
on  its  surface,  softly  or  tensely  elastic  in  consistence,  it  may  be  a 
hyperplastic  (follicular)  nodule,  a  colloid  nodule,  or  a  c\st.  Purely 
hyperplastic  nodules  are  usually  small,  and  their  clinical  significance 
is  slight.  Pure  colloid  nodules  rarely  reach  the  size  of  a  fist.  The 
differentiation  of  a  cyst  of  smaller  size  than  this  is  often  impossible 
clinically,  because  they  do  not  show  fluctuation,  but  are  softly  elastic, 
just  like  colloid  nodules. 

A  sudden  increase  in  size  and  the  onset  of  tension  points  to 
haemorrhage  within  a  cavity,  and  justifies  the  diagnosis  of  a  cyst. 

The  distinction,  however,  between  nodules  and  cysts  is  not  of 
great  therapeutic  importance,  because  nobody  treats  cysts  now  by 
pimcturing  them  or  by  opening  them  in  the  old-fashioned  way,  like 
an  abscess,  and  allowing  them  to  shrivel  up  gradually. 

Firm  or  hard  portions  indicate  fibrous  degeneration  or  calcification^ 
as  can  be  easily  demonstrated  by  Rontgen  rays.  This  change  may 
occur  both  in  colloid  nodules  and  in  cysts,  especially  in  old  people. 

There  is  an  intermediate  form  between  the  diffuse  and  nodular 
goitre,  in  which  the  whole  thyroid  gland  has  become  converted  into 
a  conglomeration  of  small  colloid  nodules. 


(2)   POSITION  OF  THE  GOITRE. 

The  point  of  origin  and  the  position  of  the  goitrous  nodule  have 
their  significance.  It  usually  arises  from  one  of  the  lateral  lobes, 
and  but  seldom  from  the  isthmus,  even  when  it  appears  to  be  just 
in  the  middle  of  the  throat.  The  sterno-mastoids  cause  it  to  follow 
this  route.  If  it  goes  on  growing  in  this  position,  it  will  finally 
become  a  pendulous  goitre,  a  variety  which  is  exceedingly  rare  in 
these  da^^s  of  operations  for  goitre.  Less  frequently  the  nodule 
glides  right  under  the  sterno-mastoid  and  appears  in  the  inferior 
lateral  triangle  of  the  neck.  But  more  dangerous  than  the  goitres 
which  make  their  way  outwards  are  those  which  remain  hidden 
under  the  sterno-mastoid,  or  make  their  way  towards  the  aperture 
of  the  thorax  instead  of  externally.  If  a  goitre  is  drawn  into  the 
thorax  on  deep  breathing,  or  is  displaced  therein  by  contraction  of 
the  sterno-mastoids,  it  is  spoken  of  as  a  wandering  goitre,  a  sunken 
goitre,  goitre  plongeant   (figs.   74  and  75).     It  is  quite  easy  to   make 


TUMOURS    AND    ALLIED   SWELLINGS    OF   THE    NECK 


149 


such  a  goitre  evident  by  swallowing,  or  making  the  patient  droop 
his  head  so  as  to  relax  the  sterno-mastoids.  A  goitre  which  is  visible 
and  palpable  in  the  neck,  but  whose  lower  extremit)^  is  so  far 
within  the  thorax  that  it  cannot  be  reached  except  by  means  of 
the  manoeuvre  just  mentioned,  is  called  a  deep  goitre.  A  goitre 
situated  mainly  or  entirely  in  the  thorax  is  called  an  infra-tlioracic 
retro-sternal  goitre.  We  shall  discuss  this  in  connection  with  media- 
stinal tumours.  The  extent  of  a  deep  or  intra-thoracic  goitre  within 
the  thorax  can  be  fairly  well  estimated  by  percussion,  and  quite 
accurately  determined  by  a  skiagram  (fig.  iii).  Diffuse  goitres  some- 
times penetrate  behind 
the  trachea  {retro-tracJieal 
goitre)  or  behind  the  oeso- 
phagus and  pharynx  (retro- 
%'isceral  goitre)  and  cause 
the  posterior  pharyngeal 
wall  to  bulge  like  a  retro- 
pharyngeal abscess.  We 
should  especially  think  of 
these  varieties  if  the  diffi- 
culties of  breathing  and 
swallowing  are  not  clearly 
explicable  by  the  palpable 
part  of  the  goitre. 

If  both  sides  are  af- 
fected, it  is  important  for 
the  purpose  of  operation 
to  know  definitely  from 
which  side  the  trouble 
mainly  arises.  As  a  rule 
it  is  not  the  side  which 
is  blamed  by  the  patient, 
and  frequently  by  the 
beginner  also  ;  in  other 
words,  not  the  side  which 
is  the  more  projecting.  Alternate  pressure  on  both  sides  of  the 
goitre,  and  especially  the  raising  of  the  one  lobule  and  the  other 
from  tlie  trachea  where  this  is  feasible,  will  very  often  show 
whence  the  difficulty  comes.  A  laryngoscopic  examination,  of 
course,  yields  more  definite  information.  It  not  only  shows  the 
lateral  displacement,  the  twisting  and  bending  of  the  larynx,  but 
also  the  convexity  of  one  tracheal  wall  or  the  flattening  of  both 
walls.  A  skiagram  demonstrates  the  entire  condition  of  the  trachea 
even  more  clearly,  and  one  should   be  taken  in  every  case  which   is 


Fig.  76. — Skiagram  of  goitre  (posterior  view). 

S  =  calcified  cyst.    T-T,  skiagram  of  trachea.     Slight 

concavity  on  right. 


:iSo 


SURGICAL   DISEASES   OF   THE   XECK 


not  quite  clear.  It  may  then  be  possible  to  tell  the  patient  before  the 
operation  that  it  is  not  the  externally  visible  goitre  which  is  to  be 
removed,  but  a  much  more  dangerous  one,  which  is  concealed. 

In  discussing  the  ano- 
malous positions  which 
goitres  may  occupy  we 
have  hitherto  assumed 
that  the  abnormallv  placed 
goitre  is  directly  con- 
nected with  the  thyroid. 
As  a  matter  of  fact,  this 
is  generally  the  case  ;  but 
the  goitre  may  have  de- 
veloped in  an  accessory 
thyroid  gland.  These  are 
termed  secondaiy  goitres, 
as  suggested  by  Wolfler. 
They  are  called  genuine  if 
they  have  no  anatomical 
connection  with  the  main 
gland,  and  false  if  they 
are  connected  with  it  by 
means  of  a  bridge  of  tissue. 
Lingual  and  tracheal 
goitres  are  always  secon- 
darv  goitres,  sometimes 
also  the  intra-thoracic 
variety,  but  the  other  forms, 
Fig.  77.-Skiagram  of  goitre  ^^^^^  ^^  retro-visceral,  are 

Severe  compression  of  trachea  on  left,     b  =  calcined         .    .   i      , 

colloid  nodule  on  right.  laten    SO. 


(3)  COMPLICATIONS  OF  GOITRE. 

HAEMORRHAGE,  IXFLAMMATIOX    AXD    MALIGXAXT 
DEGEXERATIOX. 

The  conipliccitions  of  goitre  possess  diagnostic  interest  as  well 
as  the  condition  itself.  These  complications  consist  of  hcrinorrJiage, 
inflaninnition  and  malignant  degeneration. 

(a)   Haemorrhage. 

A  patient  suffering  from  a  colloid  or  cystic  goitre  may  suddenly, 
or  sometimes  overnight,  be  seized  with  rapidly  increasing  dyspnoea^ 
combined  with  a  feeling  of  tension  in  the  goitre  and  visible  enlarge- 
ment thereof,  with  moderately  severe  pains  radiating  towards  the  jaw, 
hack   of  the    neck,  ear  and  shoulder.     These   symptoms    may  come 


TUMOURS   AND    ALLIED    SWELLINGS    OF   THE    NECK  I5r 

without  any  external  cause,  or  after  an  injury,  or  congestion  of  the- 
circulatory  system  through  coughing  or  vomiting.  They  reach  their 
maximum  in  a  short  time,  then  they  remain  at  a  standstill,  and 
subsequently  decrease  gradually.  This  assemblage  of  symptoms 
points  to  heemorrhage.  The  goitrous  nodule  is  found  to  be  tensely 
stretched,  even  hard,  somewhat  painful  on  pressure  and,  if  not  of 
great  circumference,  quite  movable.  This  mobility  enables  us  to 
exclude  forthwith  any  inflammatory  process  or  malignant  goitre  with 
similar  symptoms. 

A  colleague  of  mine  watched  his  own  goitre  in  a  mirror 
enlarging  until  severe  dyspnoea  set  in.  He  made  the  diagnosis  and 
drove  off  at  once  to  the  surgeon.  Meanwhile  the  haemorrhage  had 
attained  its  maximum  and  no  interference  was  required. 

I  once  operated  on  a  young  girl  whose  goitre  increased  during 
a  pleasant  evening's  walk  from  unnoticeable  dimensions  to  that  of  a 
medium-sized  apple.  A  little  morphia  calmed  the  dyspnoea,  and  the 
operation  which  was  done  immediately  showed  that  the  nodule  was 
tensely  filled  with  blood. 

On  another  occasion  I  was  consulted  about  a  young  girl  with- 
malignant  goitre.  The  diagnosis  had  been  based  by  an  experienced 
practitioner  on  its  hard  consistence,  radiating  pains  and  recent 
increase  in  growth.  The  nodule  was,  however,  too  movable  to 
attribute  the  radiating  pains  to  malignant  goitre,  and  further  the 
pains  and  enlargement  had  come  in  attacks  within  the  last  two 
months.  The  case  was  therefore  one  of  cystic  goitre  with  haemor- 
rhage, a  diagnosis  confirmed  by  the  operation. 

(b)   Inflammation. 

If  the  swelling  and  difficulty  in  breathing  and  swallowing  do 
not  reach  their  maximum  in  the  course  of  minutes  or  hours,  but 
only  after  a  day  or  two,  and  if  there  exist  also  severe  pain  on 
pressure,  sharp  local  and  radiating  pains,  adhesion  to  the  skin  and 
the  deeper  organs,  and  more  or  less  high  fever  from  the  beginning, . 
the  case  is  not  one  of  haemorrhage  into  the  goitre,  but  of  inflammation 
thereof — an  inflamed  goitre.  If  the  skin  is  oedematous  and  red, 
and  fluctuation  is  present,  or  if  pus  bursts  through  eventually — rarely 
into  the  trachea  or  pharynx — the  state  of  affairs  is  obvious. 

Timely  intervention  by  operation  nowadays  renders  it  impossible 
for  a  suppurating  goitre  to  burst  into  the  trachea  ;  but  even  without 
operation  this  is  a  rare  contingency.  But  on  the  other  hand  the 
pressure  of  the  goitre  on  the  trachea,  or  the  inflammatory  oedema  of 
the  laryngeal  mucous  membrane,  may  lead  to  dangerous  dyspnoea  or 
even  to  suffocation. 

Peter  Frank,  who  wrote  on  this  subject  a  century  ago,  describes 
the  case  of  a  7-year-old  lad  who  was  nearly  suffocated  by  a  suppurating. 


152  SURGICAL   DISEASES    OF   THE   XECK 

goitre.  The  village  quack  said  that  a  nerve  in  the  vicinity  of  the 
]ar3'nx  was  torn  and  that  a  fatal  result  was  unavoidable.  The  mother 
made  a  more  correct  diagnosis,  and  she  implored  the  local  barber 
to  open  the  abscess  between  the  swollen  veins.  The  desired  result 
followed. 

A  practitioner  of  the  middle  of  the  last  century  describes  how  he 
allowed  a  young  man  to  die  from  gradual  suffocation  of  an  inflamed 
goitre,  bemoaning  his  sad  fate,  but  without  the  energy  to  venture  on 
the  life-saving  incision. 

An  inflamed  goitre  is  always  of  a  metastatic  nature,  and  comes  on 
especiallv  after  scarlet  fever,  typhoid,  or  puerperal  fever,  but  also 
after  trifling  derangements  of  the  trachea  and  oesophagus — sore  throat 
or  intestinal  catarrh,  &c.  This  fact  may  be  important  in  differentiat- 
ing between  this  condition  and  haemorrhage.  The  bacteriological 
examination  of  the  pus  has  made  it  possible  to  establish  the  diagnosis 
of  a  recent  attack  of  typhoid. 

If  the  swelling  has  arisen  in  the  course  of  a  catarrhal  affection  of 
the  respiratory  tract,  there  may  be  some  doubt  about  the  diagnosis. 
The  infection  would  point  to  an  inflamed  goitre  ;  the  increased 
pressure  through  coughing  would  suggest  haemorrhage.  Xo  import- 
ance is  to  be  attached  to  a  slight  rise  in  temperature,  because  this 
may  occur  in  haemorrhage,  quite  apart  from  the  catarrh.  The 
differentiation  depends  upon  the  whole  course  of  the  symptoms  and 
upon  the  local  findings.  If  the  tumour  is  immovable  and  there  is 
considerable  local  heat  and  pain  on  pressure,  the  case  is  one  of 
inflamed  goitre,  notwithstanding  that  the  other  symptoms  may  be  in 
accord  with  the  diagnosis  of  haemorrhage. 

The  noruial  thyroid  gland  may  inflame  just  as  a  goitre.  This 
usually  occurs  after  infectious  diseases,  especially  typhoid,  malaria, 
influenza  and  articular  rheumatism,  but  may  occur  as  a  clinically 
primary  disease.  This  is  not  an  inflamed  goitre,  but  a  thyroiditis — a 
condition  insufficiently  recognized.  Just  as  in  the  case  of  an  inflamed 
goitre,  this  does  not  always  lead  to  suppuration,  but  may  resolve  in 
the  course  of  a  few  days.  This  is  the  form  which  follows  acute 
rheumatism,  malaria  and  influenza,  and  is  also  the  clinically  primary 
form.  It  is  best  termed,  as  Mygind  suggested,  simple  tliyroiditis.  It 
is  not  always  easy  to  decide  whether  there  is  any  suppuration,  and 
if  spontaneous  resolution  occur  it  does  not  by  any  means  signify  that 
there  was  no  pus. 

In  a  case  reported  by  Breuer  as  one  which  ran  its  course 
apparentlv  without  suppuration,  I  found  at  the  autopsy,  seven 
months  afterwards,  a  small  abscess  with  inspissated  staphylococcal 
pus. 

Suppuration  can  as  a  rule  be  diagnosed  by  attention  to  the 
temperature  chart  and  to  the  increasing  adhesion  of  the  gland  to  the 
adjacent  organs,  which  circumstances  show  the  necessity  for  early 
surgical  mtervention. 


TUMOURS    AND    ALLIED    SWELLLVGS    OF   THE   XECK  153 

Sometimes  the  inflammation  travels  over  the  whole  gland  in  the 
course  of  a  few  weeks,  and  finally  attacks  the  pyramidal  lobe,  when 
the  inflammation  of  the  lateral  lobes  has  gone  down.  Recurrences, 
with  intervals  of  months  or  years,  take  place  but  rarelv. 

There  is  one  important  dift'erential  sign,  in  the  initial  stage, 
between  an  inflamed  goitre  and  thyroiditis,  apart  from  the  historv 
of  the  goitre.  This  depends  upon  the  fact  that  the  swelling  in  an 
inflamed  goitre  is  usually  limited  to  one  individual  lobule,  but 
nevertheless  may  attain  a  considerable  circumference,  whereas  in 
thyroiditis  a  whole  lobe,  if  not  the  whole  gland,  is  affected,  and  still 
the  swelling  does  not  exceed  the  size  of  a  goose's  egg.  The  extension 
of  the  inflammation  over  the  whole  of  the  thyroid  gland  indicates 
thyroiditis. 

(c)  Malignant  Degeneration. 

Inflamed  goitre  and  malignant  goitre  are  occasionally  mistaken 
for  one  another,  and  errors  of  diagnosis  are  made  in  both  directions. 
1  have  seen  cases  of  indefinitely  outlined  swellings  of  the  thyroid, 
with  redness  of  the  skin  and  pyrexia,  and  with  rapid  growth,  declare 
themselves  as  sarcomata  at  the  operation.  On  the  other  hand  a 
chronic  inflammation  in  an  old  hard  goitrous  lobule  mav  present  all 
the  clinical  signs  of  malignant  growth,  including  even  metastases 
and  a  fatal  result.  It  is  quite  impossible  to  distinguish  between  those 
rare  conditions  syphilis  and  tubercle  of  the  thyroid  on  the  basis  of 
the  clinical  symptoms.  If  the  clinical  course,  the  history,  and  a  posi- 
tive Wassermann  reaction  suggest  syphilis,  and  if  the  symptoms  are 
not  urgent,  a  trial  of  specific  treatment  is  indicated.  Otherwise,  any 
suspicion  of  malignancy  demands  operation  without  delay.  Hitherto, 
tubercle  has  been  first  discovered  at  the  .operation,  or  more  correctlv 
speaking  has  been  recognized  on  histological  examination,  there 
having  been  no  clinical  symptoms. 

A  malignant  goitre  can  usually  be  confidently  diagnosed  from  the 
following  signs: — 

(a)  An  unexplained  steady  growth  of  a  goitrous  nodule  in  a  patient 
over  30  years  of  age. 

(6)  The  onset  of  hoarseness  not  accounted  for  by  the  size  of  the 
tumour  (paralysis  of  the  recurrent  laryngeal). 

(c)  Radiating  pains  towards  the  jaw,  ear,  back  of  neck  and 
shoulder  without  any  acute  inflammatory  symptoms  or  signs  of 
haemorrhage. 

(d)  Diminution  of  mobility,  irregularity  and  unevenness  in  form, 
and  hard  consistence  of  the  goitre. 

As  long  as  the  malignant  degeneration  is  limited  to  the  interior 
of   the  goitrous  lobule,   the  unexplained  growth   is  its  only  striking 


154 


SURGICAL   DISEASES    OF   THE   NECK 


feature.     There    is    neither  hoarseness  nor  radiating  pain.     Nothing 
short  of  the  microscope  can  yield  a  positive  diagnosis. 

I  once  removed  a  malignant  goitre  in  such  a  case,  thinking  it  was 
an  innocent  growth.  Unfortunately  no  microscopic  examination 
was  made,  but  a  recurrence  of  the  cancer  first  notified  me  of  the 
error  and  enforced  the  lesson  that  every  goitre  removed  should  be 
examined  for  malignancy. 

On  the  other  hand,  a  contracting  cancer  and  even  a  sarcoma,  in 
consequence  of  early  adhesions  with  adjacent  structures,  may  cause 
hoarseness,  radiating  pains,  possibly  also  narrowing  of  the  pupils  and 

other  signs  of  sympathetic 
paralysis,  while  the  growth 
itself  has  not  yet  attracted 
the  attention  of  the  patient 
and  may  really  require 
looking  for. 

Operation  must  never  be 
delayed  until  all  the  signs 
of  inalignancy  are  present, 
because  the  aim  is  not  dia- 
gnosis but  cure.  The  pro- 
gnosis in  nu'dignant  goitre 
is  only  favourable  as  long 
as  the  growth  is  within  the 
capsule  of  the  goitre,  and 
therefore  must  be  suspected 
rather  than  diagnosed. 

The  distinction  between 
sarcoma  and  carcinoma 
need  not  detain  us,  because 
even  the  interpretation  of 
the  histological  appear- 
ances is  not  always  easy. 
The  differentiation  between 
the  various  forms  of  car- 
cinoma appears  to  be  of 
even  less  practical  importance  so  far.  But  it  should  be  observed  that 
the  adenomatous  variety  (the  "proliferating  goitre"  of  Langhans) 
runs  a  remarkably  slow  course,  despite  the  presence  of  all  the  signs 
of  malignancy. 

On  one  occasion  I  declined  a  further  operation  on  a  female  patient 
suffering  from  paralysis  of  the  recurrent  laryngeal,  with  extensive 
adhesions  and  thrombosis  of  the  veins  of  the  neck,  and  informed 
the  friends  that  the  course  of  the  disease  would  be  rapid.  The  patient, 
however,  lived  for  nearly  ten  years  in  great  suffering. 


Fig.  78. — Malignant  Goitre  (from  the  Surgical 
Clinique  at  Berne). 


TUMOURS   AXD    ALLIED    SWELLIXGS    OF    THE    NECK  155 

The  uiefastafic  ^roivtJis  from  thyroid  gland  tumours  have  certain 
special  characteristics  which  are  also  of  diagnostic  interest. 

Colloid  goitres,  which  are  clinically  and  histologically  apparently 
innocent,  sometimes  give  rise  to  metastases,  especially  in  the  bones, 
with  a  structure  partly  composed  of  normal  thyroid  tissue,  partly  of 
colloid  goitre  and  partly  of  cancer. 

Sometimes  the  metastases  of  definite  thyroid  gland  cancers  consist 
of  normal  thyroid  tissue  by  way  of  atavism. 

All  forms  of  cancer  of  the  thyroid  have  a  predilection  for  metastases 
in  the  osseous  svstem. 

Growths  independent  of  the  thyroid  gland  which  occur  in  the 
anterior  triangle  of  the  neck  are  rapidly  disposed  of.  They  are 
branchial  cleft  cysts,  or,  when  situated  in  the  median  line  in  front  of 
the  thyroid  cartilage,  they  are  cysts  of  the  iliyro-glossal  duct.  We 
shall  discuss  these  in  connection  with  the  other  cysts  of  the  neck. 

Z^.— TCMOURS    OF   THE    SIDE    OF   THE    XECIv    AND    ITS 

VICINITY. 

The  tumours  which  are  found  at  the  side  of  the  neck  differ 
widely  in  character,  and  in  order  to  avoid  repetition  we  shall  include 
among  them  new  growths  under  the  sterno-mastoid  and  those  which 
occur  in  the  submaxillary  and  parotid  regions. 

(1)    ENLARGEMENT  OF  THE   LYMPHATIC  GLANDS. 

In  the  first  place  we  must  be  quite  sure  whether  we  are  not 
dealing  with  enlargement  of  the  lymphatic  glands.  These  always 
declare  themselves  by  their  number  and  their  arrangement  in  groups. 
If  a  tumour,  which  is  apparently  single,  is  really  made  up  of  separate 
lumps  or  nodules,  we  must  think  of  a  mass  of  adherent  glands. 
Appreciable  swelling  of  one  individual  gland  may  occur,  both  in 
tubercle  and  in  secondary  malignant  degeneration,  but  is  not  common 
in  either. 

If  we  recognize  the  tumour  to  be  of  glandular  origin,  it  may  be 
due  either  to  inflammation,  or  to  new  growth,  or  to  the  intermediate 
condition  of  malignant  lymphoma. 

I  am  not  treating  now  of  acute  inflammation  of  the  cervical 
glands.  Their  behaviour  is  similar  to  that  of  the  abscesses  to  which 
they  give  rise,  to  the  description  of  which  the  reader  is  referred. 

If  a  child  suffering  from  eczema  or  a  chronic  mucous  membrane 
•catarrh  has  enlarged  glands  in  the  area  drained  by  the  corresponding 
lymphatics,  the  diagnosis  is  simple  lymphadenitis.  We  must  assume 
that  the  glands  have  been  affected  by  the  constant  introduction  of 
mildly  virulent  organisms  or  by  their  toxins. 

Foi-meiiy,  simple  and  tubercular  lymphadenitis  were  included 
II 


156 


SURGICAL   DISEASES   OF   THE   XECK 


under  the  one  term  ^'scrofula."  To-day  this  term  has  no  meaning, 
unless  we  reserve  it  to  express  that  general  state  of  lowered  resistance 
which  is  due  to  hereditar}'  causes  (alcohol  and  syphilis),  and  to 
unfavourable  hygienic  surroundings,  and  which  prepares  the  soil  for 
various  micro-organisms.  If  the  tubercle  bacillus  be  among  these — 
a  very  frequent  circumstance — then  scrofula  becomes  tuberculosis. 
Adolf  Czernv  and  his  school  apply  the  term  "  exudative  diathesis " 
to  anv  condition  wherein  there  is  hyper-sensitiveness  to  infective 
organisms,  and  they  only  speak  of  "scrofula  "'  if  a  tubercular  infection 
is  super-added  to  this  diathesis. 

Even  the  beginner  knows  that  a  chain  of  nodules  which  are  partly 
elastic  and  movable,  partly  hard  and  infiltrated  or  even  fluctuating,  are 

tubercular.  Scattered 
scars  indicate  to  hmi  that 
the  disease  is  not  recent, 
and  that  there  is  no  reason 
to  entertain  the  idea  of 
malignancy  (fig.  79).  If 
there  be  but  little  pain,  and 
the  mobility  is  free,  and 
the  consistence  is  elastic 
with  no  sign  of  involve- 
ment of  the  skin  despite 
their  long  existence,  we 
know  that  the  glands  are  of 
the  non-caseating,  or  of  the 
very  slowlv  caseating  va- 
riety. If  there  be  definite 
pain  on  pressure,  with  only 
slight  mobility,  and  the 
superjacent  skin  can  only 
be  picked  up  with  diffi- 
culty, it  shows  that  casea- 
tion is  proceeding  and  that 
peri-adenitis  has  begun.  If 
the  skin  has  become  red,  and  the  glands  are  fixed  and  their  firmness 
is  replaced  by  a  softlv  elastic  or  fluctuating  consistence,  there  can  be 
no  further  doubt  about  their  suppuration. 

If  a  patient  wdio  has  hitherto  been  free  from  glands,  acquires  a 
bunch  of  them  on  one  side,  within  a  short  time,  one  must  think  of 
the  possibility  of  a  syphilitic  infection,  and  a  primary  sore  must  be 
looked  for  in  the  area  drained  by  the  corresponding  lymphatics, 
especially  in  the  mouth  or  nose. 

Sometimes  it  is  difficult  to  distinguish  between  tubercular  glands 
and  the  large  glands  which  occur  in   the  course   of  such   lymphatic 


"   1 

m 

1' 

Nv'- 

\ 

Fig.   79. — Tubercular  lymphoma. 


TUMOURS   AND   ALLIED   SWELLINGS   OF   THE   NECK 


157 


diseases  as  leukaemia  and  lymphadenoma.  Leukaemic  changes  are 
very  easy  to  recognize  because  the  glandular  enlargement  is  over- 
shadowed by  the  signs  of  leukaemia — pallor,  debility  and  the  hemor- 
rhagic diathesis — and  the  examination  of  the  blood  sets  aside  any 
doubt. 

Pseudo-leukaemic  glandular  h3'perplasia,  i.e.,  malignant  lymphoma 
(lymphadenoma  or  Hodgkin's  disease)  is  equally  easy  to  recognize 
if  all  the  glandular  situations  are  affected,  if  the  liver  and  spleen  are 
enlarged  and  the  patient  has  a  cachectic  appearance,  with  blood  not 
tvpical  of  leukaemia. 

We  adhere  here  to  the 
usual  view  that  pseudo- 
leukaemia  is  a  clinical  unity, 
despite  the  fact  that  it  has 
been  shown  that  it  gradu- 
ates into  true  leukaemia  on 
the  one  hand,  and  sarco- 
matous processes  on  the 
other.  The  histological 
differentiation  of  one  type 
wherein  the  glands  are  con- 
verted into  a  kind  of  granu- 
lation tissue  (Sternberg's 
variety)  and  of  another  type 
wherein  there  is  hyperplasia 
of  the  lymphadenoid  tissue 
(Cohnheim's  variety)  is,  so 
far,  of  no  diagnostic  interest 
clinically,  because  it  is  not 
possible  to  distinguish  the 
two,  with  any  certainty,  and 
because  their  course  is  the 
same. 

Finally,  there  are  some 
rare  cases  wherein  every- 
thing points  to  Hodgkin's  disease,  but  the  bacteriological  examina- 
tion declares  for  tubercle.  Further,  pseudo-leukaemia  may  occur  in 
tubercular  subjects,  and  tubercle  may  become  engrafted  on  pseudo- 
leukaemia.  Observations  such  as  these  have  given  rise  to  the  suggestion 
that  pseudo-leukaemia  is  fundamentally  a  tubercular  disease.  The  pro- 
bability is  that  it  is  a  chronic  infection,  siii  generis,  the  organism  of 
which  (antiformin-fast  bacillus  of  Fraenkel-Much)  is  morphologicallv 
similar  to  the  tubercle  bacillus,  but  is  clinically  more  malignant.  The 
view  that  Hodgkin's  disease,  at  any  rate  Sternberg's  type,  is  caused  by 
an  attenuated  form  of  the  tubercle  bacillus  is  refuted  by  its  clinical 
course. 


Fig.  80.— Lymphadenoma  (pseudo-leukaemia) 
Early  stage. 


158 


SURGICAL   DISEASES   OF   THE   XECK 


Tubercular  glands  are  rarely  met  with,  equally  developed  in  all 
glandular  situations,  as  is  the  case  in  lymphadenoma.  They  generally 
show  some  points  of  tubercular  softening  if  the  trouble  is  widespread. 
In  the  initial  stage  when  the  neck  alone  is  affected,  and  therefore 
the  extension  of  the  glandular  enlargement  offers  no  points  of  dif- 
ferentiation, the  diagnosis  may  be  indeed  difficult.  Our  opinion 
must  be  based  on  the  size  and  condition  of  the  glands  and  their 
relation  to  the  surrounding  parts.  If  they  are  of  medium  size,  soft 
and  immovable,   it  is,  unfortunately,  impossible  to   dogmatize  about 

the  diagnosis,  because  a 
non-suppurating  form  of 
tubercular  lymphoma 
cannot  at  this  stage  be 
distinguished  from  the 
soft  variety  of  malignant 
lymphoma.  In  such  cases 
the  latter  is  always  first 
recognized  by  its  gener- 
alization, or  by  excising  a 
portion  for  examination. 
It  is  quite  different  if 
numerous  movable,  but 
hard,  glands  are  present. 
Such  a  condition  indi- 
cates the  hard  form,  or 
rather  the  hard  stage 
of  Hodgkin's  disease. 
Tubercular  glands  only 
exhibit  the  pronounced 
hardness,  which  the 
latter  disease  occasion- 
ally manifests,  after  a 
recent  inflammation.  But 
in  such  cases  signs  of 
peri-adenitis,  and  especially  of  adhesions  with  the  surrounding  tissues, 
are  present. 

It  must  not  be  supposed  that  the  glands  cannot  become  pretty 
fairly  adherent  in  lymphadenoma.  Indeed,  adhesions  do  occur,  but 
they  are  not  accompanied  by  as  much  peri-adenitic  infiltration  of  the 
tissues  as  occurs  with  caseating  tubercular  glands.  i\lthough  the 
glands  may  be  very  hard  in  lymphadenoma  their  outlines  can  be 
distinctly  felt,  and  this  serves  to  differentiate  it  from  tubercle.  The 
glands  are  also  more  prominent,  so  that  the  whole  aspect  resembles 
a  caricature  of  tubercular  adenitis.  These  considerations  suggested 
a    diagnosis   of  malignant   lymphoma    in    fig.   80,  although  the  upper 


Fig.  81. 


-More  advanced  case  of  lymphadenoma,  but 
still  confined  to  the  neck. 


TUMOURS   AND   ALLIED   SWELLINGS   OF  THE   NECK  1 59 

glands  only  were  affected.  A  small  portion  excised  for  examination 
confirmed  this  diagnosis.  I  have  even  seen  diffuse  necrosis — not 
caseation — in  cases  of  Cohnheim's  type,  as  in  some  of  the  glands 
depicted  in  fig.  81,  in  which  case  tubercle  was  excluded  by  micro- 
scopic examination  and  annual  inoculation. 

Blood  examination  affords  but  little  information.  It  merely 
reveals  the  signs  of  an  ordinary  moderately  severe  anaemia,  possibly 
also  a  relative  increase  in  the  lymphocytes.  There  is  one  rather  rare 
symptom  which  is  in  favour  of  lymphadenoma  (and  leukaemia),  and 
against  tubercle,  as  showing  that  the  bone  marrow  participates  in  the 
disease,  and  that  is,  severe  pain  on  percussion  over  the  sternum. 

The  stress  laid  upon  the  differential  diagnosis  from  tubercle  is 
justified  by  the  great  difference  in  the  prognosis  of  the  two  diseases. 

Malignant  enlargement  of  glands  is  especially  indicated,  when 
they  are  hard,  contract  early  adhesions  to  surrounding  parts,  and 
cause  radiating  pain.  It  is  often  verv  difficult  to  demonstrate  the 
primary  tumour,  because  it  frequently  bears  no  relation  in  size  to 
the  extent  of  the  glandular  enlargement  and  may,  therefore,  lie  in  a 
very  concealed  situation. 

I  once  found  a  small  carcinoma  at  the  hinder  end  of  the  middle 
turbinate  bone  (fig.  82),  as  the  primary  growth  in  a  case  of  consider- 
able enlargement  of  the  glands  at  the  side  of  the  neck.  In  another 
case  the  primary  growth  was  at  the  posterior  border  of  the  septum 
nasi. 

A  growth  in  the  neck  can  only  be  regarded  as  primary,  if  a  careful 
search  has  excluded  cancer  from  the  various  sites  of  the  internal 
mucous  membrane  which  are  usually  attacked. 

If  the  cancerous  infiltration  has  gone  beyond  the  glands,  and  has 
penetrated  the  skin  and  become  secondarily  infected,  it  is  very  liable 
to  be  mistaken  for  a  chronic  inflammatory  process  (fig.  83). 

On  the  other  hand,  there  are  certain  very  rare  cases  wherein  can- 
cerous glands  have  an  elastic  consistence  and  are  very  late  in 
contracting  adhesions.  Sometimes  it  is  quite  impossible,  even  at 
the  operation,  to  distinguish  these  from  hyperplastic  tubercular 
lymph  oraata. 

(2)  TUMOURS  WITH   LIQUID  CONTENTS. 

If  we  have  excluded  disease  of  the  lymphatic  glands,  and  at  the 
same  time  recognize  that  the  growth  is  a  tumour  in  the  widest  sense 
of  the  term,  further  deductions  nuist  be  based  primarily  on  its 
consistence. 

If  a  tumour  at  the  side  of  the  neck  is  soft  or  elastic  in  consistence, 
or  if  it  fluctuates,  we  must  conclude  that  its  contents  are  fluid.  We 
can  only  be  misled  by  a  lipoma,  which  also  has  a  soft  or  elastic  con- 
sistence, but  subcutaneous  lipomata  may  be  recognized  by  theu^ 
lobular  structure  and  the  deep  subfascial  lipomata  are  too  rare  to 
merit  early  consideration. 


i6o 


SURGICAL    DISEASES    OF   THE    NECK 


The  liquid  contents  of  the  tumour  may  consist  of  lymph,  blood  or 
the  product  of  an  epithelial  secretion.  The  Hquid  is  either  in  numerous 
small  vesicles  or  within  one  large  cavity,  or  both  conditions  may  be 
combined.  This  already  gives  rise  to  a  large  number  of  varieties, 
which  are  increased  bv  the  circumstance  that  the  blood  within  these 
tumours  may  be  either  arterial  or  venous. 

The  variety  is,  however,  not  so  great,  if  we  leave  a  few  rarities 
out  of  account  and  limit  ourselves  to  a  small  number  of  typical 
conditions,  whose  diagnosis  is  not  difficult. 

{a)   If  the  growth   is  so   near  the    surface    that  its   contents  gleam 
through,  but  not  with  dark  blue  colour  indicative  of  blood,  the  case 

is  one  of  lymph  tumour 
-  {i.e.,  lymph  cyst)  if  the 
growth  is  smooth  and 
round,  but  is  a  cavernous 
lymphangioma  if  it  appears 
to  be  multilocular  or 
spongy  in  consistence. 
These  tumours  look  red- 
dish in  transmitted  light 
and  light  blue  in  direct 
light,  if  the  skin-covering 
is  thinned  out  sufticienlly. 
In  addition,  lymph- 
containing  tumours  react 
much  less  to  changes  in 
^j^-^-  -  \      -wm^w    -^  -  states  of  pressure  (posture 

j^H^  ,  of  body,    squeezing)    than 

^*^  --'      do  blood-cysts,  and  their 

contents    are     much     less 
displaceable. 

If  a  growth  of  the  neck 
resembles  a  blood  tuuKjur  in  coloui-,  but  has  all  the  other  characters 
of  a  lymph  cyst,  we  must  first  ascertain  whether  it  has  been  punctured. 
A  puncture  may  sometimes  cause  the  contents  of  a  lymph  cyst  to 
remain  permanentlv  bloody. 

We  have  just  drawn  a  distinction  between  one-chambered  lymph 
cysts  and  cavernous  lymphangiomata,  but  there  is  really  no  sharp 
differentiation  between  the  two.  The  most  pronounced  hmiph  cysts 
permeate  deeply  among  muscles  by  means  of  cavernous  strands,  and 
manv  cavernous  Ivmphangiomata  contain  large  cystic  cavities  between 
spongy  portions. 

The  diagnosis  of  cystic  lymph  tumours  is  facilitated  by  the  cir- 
cumstance   that    thev    occur    in    two   well-defined    forms,    viz.,    cystic 


Fig.  82, — Cancerous  glands,  with  small  primary 
growth  on  the  middle  turbinated  bone.  (From  the 
Surgical  Clinique  at  Berne). 


TUMOL'RS    A\D    ALLIED    SWELLINGS    OF    THE    XECK 


l6l 


lyinplidiigioiiia  of  infants  (congenital  cystic  hygroma  of  the  neck), 
and  the  lateral  lymphatic  cyst  of  adults.  The  former  is  present  at 
birth,  and  is  situated  in  the  upper  part  of  the  anterior  triangle  of 
the  neck,  below  the  parotid  region.  It  spreads  thence,  rapidlv 
increasing  in  size,  to  all  sides,  and  if  bilateral  it  encircles  the  neck 
like  a  collar.  As  it  approaches  nearer  and  nearer  to  the  skin,  the 
latter  becomes  thinned  out  in  places  to  a  line  membrane,  and  at 
the  same  time  the  cyst  penetrates  deeply  between  the  muscles  and 
interferes  with  the  structures  in  the  neck,  through  its  increasing 
extent.  Sometimes  it  is 
possible  to  feel  hard 
fibrous  portions  situated 
within  the  soft  elastic 
cysts,  and  the  whole  tu- 
mour shakes  like  jelly  on 
being  moved. 

The  lymphangiomata 
of  adults  are  mostly  situ- 
ated in  the  supra-clavicu- 
lar fossa,  and  occur  gen- 
erally in  women.  They 
consist  either  of  large 
single  cysts  or  of  a  con- 
glomeration of  smaller 
cysts. 

The  growth  illustrated 
in  fig.  84  consisted  of 
one  large  cavity,  and  of 
a  pedicle  made  up  of  di- 
lated lymph  spaces,  which 
ran  down  deeply  among 
the  cervical  muscles. 

The  purely  cystic  forms 
are  liable  to  be  confused 
with  branchial  cleft  cvsts, 

which  will  be  discussed  subsequently.  In  adults  the  lymph  does 
not  gleam  through  the  skin  as  clearly  as  it  does  in  children.  Both 
growths  are  essentially  congenital  in  origin,  but  thev  do  not  develop 
till  later  years.  If  the  cyst  is  situated  very  much  to  the  side,  this  is 
the  only  sign  really  valuable  for  the  diagnosis  of  lymphatic  c^^st: 
positive  accuracy  can  only  be  obtained  by  puncturing  the  cyst  and 
microscopic  examination  of  a  portion  of  its  wall. 

(/))   If  the    contents    of  the  tumour   look    dark  blue   through   the 
thin    skin,    the    case    is  one   of  a   blood-tumour.     If   the    surface    is 


Fig.  83. — Diffuse  carcinoma  of  neck.  Primary 
growth  on  tonsil.  (Resembles  actinomycosis,  or  board- 
like phlegmon). 


l62 


SURGICAL   DISEASES   OF   THE   NECK 


irregular  and  rough,  it  is  called  a  cnvenioiis  angioma,  and  if  it  is  round 
and  regular  it  is  known  as  a  blood-cyst.  In  both  varieties  the 
contents  of  the  cysts  are  definitely  expressible,  thus  contrasting  with, 
lymphangiomata;  but  as  soon  as  the  pressure  is  relaxed  the  cyst 
immediately  fills  up.  A  deeply  situated  venous  blood-tumour  is  not 
recognizable  by  its  colour,  but  it  becomes  inflated  when  the  intra- 
thoracic pressure  is  raised  by  coughing,  crying  or  squeezing,  or  by- 
keeping  the  head  low.  This  sign  distinguishes  it  from  a  deep  lipoma 
of  lymphangioma. 

As  we  have  mentioned  the  matter  of  expressibility,  we  must  again 

refer  to  divert icuhnn  of  the 

cesophagus.      Its    contents 

i  can    also     be    expressed,. 

but  it  does  not  fill  up 
forthwith  when  the  pres- 
sure is  relaxed.  The  dia- 
gnosis is  readily  made 
from  the  history  and  the 
fact  that  there  is  difficulty 
in  swallowing  when  the 
diverticulum  .fills  up, 
owing  to  pressure  on  the 
gullet. 

{c)  The  tuinours  con- 
taining venous  blood  just 
referred  to,  proclaim  the 
nature  of  their  contents 
by  their  colour  and  ex- 
pressibility ;  but  struc- 
tures filled  with  arterial 
blood,  aneurisms,  pos- 
sess another  characteristic 
symptom,  viz.,  pulsation. 
This  feeling  of  pulsa- 
tion may  be  appreciated 
under  three  different  cir- 
cumstances : — 
(i)  The  tumour  itself  may  pulsate— expansile  pulsation. 

(2)  The  tumour  may  be  rhythmically  raised  by  the  pulsation  of 
the  carotid  artery — a  communicated  pulse. 

(3)  The  carotid  artery  itself  may  be  pushed  forward  by  a  tumour 
lying  beneath  it. 

In  order  to  differentiate  between  these  conditions,  one  must 
endeavour  to  grasp  the  tumour  between  two  fingers.  If  these  are 
stretched  apart  from  each  other,  in  all  situations  and  in  all  directions, 
the  pulse  is  then  an  expansile  one.  If  the  fingers  are  hfted  with 
each  pulsation,   but  ai'e  not  stretched    apart,    the   tumour  is  merely 


Fig.  84. — Lymphatic  cyst  at  the  side  of  the  neck. 


TUMOURS    AND    ALLIED    SWELLINGS    OF   THE    NECK  163 

raised  by  the  carotid — it  belongs  to  the  second  variety.  If  only  a 
pulsating  strand  is  felt  over  the  tumour,  while  the  rest  shows  no 
pulsation,  the  tumour  lies  under  the  carotid. 

If  an  expansile  pulse  really  exists,  the  beginner  is  apt  to  think 
at  once  of  an  aneurism  ;  but  very  vascular  sarcomata  may  also  yield 
an  expansile  pulse  and  be  accompanied  by  loud  haemic  murmurs. 

Although  a  vascular  goitre  may  have  a  pronounced  expansile 
pulse,  it  could  only  be  mistaken  for  an  aneurism  after  a  very  in- 
different examination.  A  vascular  goitre  usually  affects  the  whole 
thyroid,  and  is,  therefore,  bilateral.  The  fact  that  it  follows  the 
movements  of  deglutition  ought  to  remove  any  doubt. 

The  carotid  artery  sometimes  undergoes  dilatation  in  old  syphilitic 
subjects  at  the  point  of  bifurcation,  and  this  may  lead  the  beginner 
to  think  that  an  aneurism  is  developing. 

If  he  overlooks  the  pulsation  and  neglects  to  examine  the  other 
side,  he  may  regard  the  swelling  as  an  enlarged  gland,  especially  if 
the  presence  of  a  cancer  of  the  lip  causes  him  to  look  for  one. 

A  communicated  pulse  may  be  observed  in  enlarged  glands  lying 
on  the  carotid  artery,  goitrous  nodules  and  other  tumours,  especially 
deep-lying  branchial  cleft  cysts. 

The  mistakes  which  occur,  owing  to  the  carotid  pulsating  ///  front 
of  a  pathological  structure,  mainly  concern  hnrrowing  abscesses  and 
deep  sarcomata  of  the  uecli.  Similarly  a  subclavian  artery,  pushed 
forward  by  a  cervical  rib,  has  often  been  diagnosed  as  an  aneurism. 

The  etiology  is  always  an  important  factor  in  the  diagnosis  of 
aneurism.  Arterial  dilatation  is  always  preceded  by  some  morbid 
condition  of  the  vessel  wall,  produced  by  arteriosclerosis  or  syphilis, 
or  is  the  result  of  some  trauma. 

If,  after  considering  all  these  points,  we  arrive  at  the  diagnosis 
of  aneurism,  we  must  determine  the  artery  whence  it  arises.  If  the 
tumour  is  behind  the  sterno-raastoid  we  should  think  of  the  carotid, 
and  if  it  seems  to  start  low  down  its  origin  will  probably  be  at  the 
root  of  this  artery.  The  delay  of  the  pulse  in  the  temporal  artery 
is  an  important  corroborative  sign,  but  its  absence  is  not  an  uncon- 
ditional proof  against  aneurism.  If  the  tumour  is  situated  high  up 
and  it  displaces  the  tonsillar  region  inwards,  it  can  be  nothing  but 
an  aneurism  of  the  external  or  internal  carotid.  If  the  temporal 
pulse  is  weakened  and  delayed,  we  must  conclude  that  it  is  an 
aneurism  of  the  external  carotid — the  more  frequent  variety. 

If  an  aneurismal  swelling  is  found  in  the  supra-clavicular  fossa, 
there  is  no  difficulty  in  diagnosing  an  aneurism  of  the  subclavian 
artery.  Weakening  and  delay  of  the  pulse  in  the  corresponding 
radial,  pressure  signs  referable  to  the  brachial  plexus,  are  the  classical 
symptoms. 


164 


SURGICAL   DISEASES   OF   THE   NECK 


It  is  necessary  to  mention  a  very  rare  condition,  which,  however, 
the  experience  of  recent  wars  with  modern  firearms  shows  to  be 
getting  more  frequent.  In  this  condition  the  region  of  the  common 
carotid  presents  a  scar  resulting  from  a  gunshot  wound,  stab  or  cut, 
beneath  which  there  is  a  pulsating  tumour,  varying  in  size  from  a 
walnut  to  a  hen's  egg,  with  haemic  murmurs  audible  over  it.  The 
patient  complains  of  symptoms  pointing  to  disturbance  of  the 
cerebral  circulation,  and  the  superficial  veins  of  the  corresponding 
side  of  the  head  and  neck  are  dilated.  This  condition  is  one  of 
arterio-venous  aneurism,  and  is  caused  by  a  simultaneous  injury  to 
the  common  carotid  artery  and  internal  jugular  vein.  Exceptionally 
a  similar  condition  may  occur  in  connection  with  other  arteries  of 
the  neck,  viz.,  the  external  carotid  and  subclavian. 

There  is  a  difference  between 
an  artcrio-vcnous  aneurism  proper, 
wherein  the  blood  exists  in  a  space 
between  the  artery  and  vein,  and 
an  niieitrisinal  varix,  wherein  the 
blood  flows  directly  from  the 
artery  into  the  vein.  The  former 
is  somewhat  irregular  in  outline, 
jSji^^^  fhe  latter  is  more  circular  in  shape. 

-JbP^W'  (</)  A  cervical  cyst,  which  does 

TBi'lillliP™  j-iq|.  £^  -j^  ^^,j+|^  ^^^y  Qj-  ^YiQ  groups 

just  described,  one  which  is 
neither  a  blood  nor  a  lymph  cyst 
— is  probably  an  epithelial  cyst 
arising  from  some  congeiiiinl 
riuliiiieiif. 

If  it  is  situated  in  the  middle 
line  above  the  thyroid  gland  it 
arises  from  the  thyro-glossal 
duct,  which  runs  from  the  foramen  caecum  at  the  base  of  the  tongue 
towards  the  thyroid  gland.  A  cyst  in  the  course  of  this  duct  must  be 
ascribed  to  its  imperfect  obliteration,  whether  it  contain  mucus  or 
epithelial   debris. 

It  might  be  mistaken  for  a  swelling  of  the  sub-hyoid  bursa,  a 
median  goitrous  cyst,  a  simple  sebaceous  cyst  of  the  region,  or  even 
for  an  abscess  in  connection  with  the  hyoid  bone.  But  these  are 
all  rare  eventualities,  which  can  only  be  deiinilely  determined  by 
the  microscope.  But  the  history  will  allow  us  to  distinguish  between 
a  cyst  on  the  one  hand,  and  some  suppurative  process  on  the  other. 
Exceptionally,  such  a  median  cyst  may  be  displaced  as  far  as  the 
root  of  the  neck. 

If  the  cyst  is  situated  laterally,  at  the  inner  border  of  the  sterno- 


FiG.  85. — Deep  cyst  of  the  branchial  cleft. 
(Deep  dermoid  of  neck.) 


TUMOURS    AND    ALLIED    S\VELLL\GS    OF   THE    XECK  165 

mastoid,  or  even — in  its  lower  portion — at  its  outer  border,  anatomical 
research  shows  that  it  is  derived  from  the  second,  or  even  from  the 
third  and  fourth,  branchial  cleft.  It  will  contain  mucus,  muco-serous 
fluid,  or  fat  and  epithelial  debris,  like  a  dermoid,  varving  with  its 
lining  epithelium.  The  skin  covering  it  is  usually  normal  :  but 
where  it  is  thinned  there  is  an  absence  of  the  translucent  appearance 
seen  in  a  lymphatic  cyst.  These  cysts  often  stand  forth  quite  distinctly 
and  well  defined  above  the  level  of  the  surrounding  skin.  There  is 
one  group  of  cases  in  which  we  can  feel  an  oval  structure  Iving 
deeply  beneath  a  diftuse  indefinite  prominence  of  one  side  of  the 
neck.  If  the  head  is  turned  towards  the  opposite  side,  the  sterno- 
mastoid  can  be  felt  to  contract  over  it.  These  tumours  have  been 
described  as  deep  dermoids  of  the 
neck  (fig.  85);  but  there  is  no  justi- 
fication for  separating  them  from 
cysts  of  the  branchial  cleft.  Their 
origin  from  the  pharvngeal  epi- 
thelium is  betrayed  bv  the  abund- 
ant lymphoid  tissue  which  is 
deposited  in  their  epithelial  layer 
stratum. 

The  diagp.osis  of  the  so-called 
branchial  cleft  cvsts  is  not  usuallv 
difficult,  even  when  the  tumour 
is  completely  closed  in.  But  in 
most  cases  there  is  a  small  depres- 
sion in  the  skin  over  the  tumour, 
which  renders  it  impossible  to  mis- 
take the  condition,  and  facilitates 
the  diagnosis  for  beginners.     The 

i-       4.  1     1  1      •    r  >i      -  Fk;.  86. — Sebaceous  cyst,  in  exact  posi- 

patient  probably  mforms  us  that  a       ^-^^  ^f  ^^^-^^^  ^yst  of  neck,  but  more 

whitish  fluid  exudes  from  it  occa-       superficial. 

sionally,  whereupon    the  "gland" 

vanishes,  only  to   reappear    again    in   a   short    time.     Sometimes  this 

evacuation    is    preceded    by   an   inflammatory  attack,   and    then    the 

exudation   is  more  or  less   purulent.     The  picture  is  complete  if  we 

find  a  small  scar  in  the  vicinitv  of  the  sinus.     We  must  not  be  misled 

into  diagnosing  tubercular  glands,  because  we  find  the  condition  on 

both  sides.      Branchial   cleft   cysts  and  sinuses  may  occur  on   both 

sides,  symmetrically  arranged. 

Sebaceous  cysts  situated  ///   the  skin,  in  favourite  situations  of    the 

neck,  must  not  be  mistaken  for  branchial  cleft  cvsts. 


l66  SURGICAL   DISEASES   OF   THE   NECK 

(3)  SOLID  TUMOURS  OF  THE  NECK. 

We  now  proceed  to  deal  with  the  solid  tumours  of  the  neck.  As 
we  have  already  mentioned,  a  lipoma  is  on  the  borderland  between 
the  fluid  and  solid  tumours,  and  we  sliould  think  of  it  when  palpation 
leaves  us  in  doubt  as  to  which  variety  is  in  question.  We  shall  not 
here  refer  to  the  easily  recognizable  superficial  lipoma,  which  we  shall 
discuss  in  connection  with  tumours  at  the  back  of  the  neck — the 
usual  site  of  this  tumour.  The  deep  suh-fascial  lipoma  occurs,  but 
rarely,  to  add  to  diagnostic  difficulties  ;  and  although  it  is  well  defined^ 
its  processes  permeate  between  the  various  organs  in  the  neck. 

The  questions  which  centre  around  most  solid  tumours  of  the 
neck  are  quite  of  a  different  character.  These  tumours  are  usually 
distinctly  firm  in  consistence,  if  not  hard,  and  we  have,  therefore,  to 
decide  between  fibroma,  sarcoma,  and  carcinoma. 

Having  recognized  that  the  tumour  is  primary,  the  question  of 
its  innocence  or  malignancy  arises.  If  the  growth  has  taken  years 
to  develop,  and  still  remains  movable,  it  must  be  regarded  clinically 
as  innocent,  though  it  should  not  be  forgotten  that  a  fibroma  of  the 
neck  may  be  on  the  borderland  between  innocence  and  malignancy^ 
and  that  it  may  spontaneously  become  malignant  after  many  years^ 
existence. 

It  is  only  in  a  very  few  definite  situations  that  any  question  of 
dift'erential  diagnosis  can  arise  as  between  a  fibroma  and  some  other 
innocent  tumour.  It  may,  however,  occur  in  the  neighbourhood  of 
the  submaxillary  or  parotid  gland,  including  the  region  behind  the 
ear.  For  the  purpose  of  making  a  general  survey,  we  propose  to 
discuss  separately  the  various  sections  of  the  side  of  the  neck. 

(a)    Submaxillary  Region, 

Chronic  inflammatory  processes  are  occasionally  observed  in 
the  siibiiiaxillarv  gland,  leading  to  its  enlargement  through  increase  of 
the  connective  tissue,  while  the  glandular  tissue  itself  diminishes. 
The  diagnosis  generally  points  to  new  growth,  and  the  comparatively 
rapid  growth  usually  suggests  malignancy.  It  is  quite  easy  to 
demonstrate  by  palpation  that  the  growth  is  connected  with  the 
submaxillary  gland. 

As  it  is  not  always  possible  to  distinguish  this  condition  accurately 
from  a  real  tumour  without  the  microscope,  and  as  the  loss  of  one 
submaxillary  gland  is  not  a  very  serious  matter,  the  course  will  usually 
be  adopted  of  removing  the  structure. 

This  chronic  inflammation  of  a  single  submaxillary  gland  must 
not    be    confused    with  the  symmetrical  chronic  inflammation  of  all 


TUMOURS    AND    ALLIED    SWELLINGS    OF   THE    NECK  167 

the  salivary  and  lachrymal  glands,  known  as  Mikulicz's  disense.  In 
some  cases  this  enlargement  is  merely  one  manifestation  of  leukaemia 
or  lymphadenoma.  Tuberculosis  of  the  submaxillary  gland  is  so  rare, 
that  it  can  only  be  recognized  by  the  microscope,  unless  the  diagnosis 
is  suggested  by  a  chronic  abscess. 

Omitting  rarities,  the  only  innocent  tumour  among  those  which 
are  genuine  growths,  which  we  need  consider,  is  the  so-called  mixed 
tumour.  A  movable  hard  tumour  which  has  slowly  grown  in  the 
submaxillary  region  is  a  fibroma  of  the  neck,  if  we  can  feel  the 
salivary  gland  quite  separate  from  it,  on  making  bi-manual  palpation, 
externally  and  in  the  mouth.  If  the  gland  cannot  be  demonstrated 
as  distinct  from  the  tumour,  and  if  it  has  a  smooth  surface,  it  is 
suspicious  of  chronic  fibroid  inflammation  of  the  salivary  gland. 
If  the  new  growth  is  perfectly  movable,  but  has  a  strikinglv  nodulated 
surface  and  has  existed  for  years,  we  should  regard  it  as  a  so-called 
mixed  tumour.  If  we  learn  that  the  tumour  has  been  noticed 
for  many  years,  but  that  the  rate  of  gipwth  has  increased  rapidly 
within  the  last  few  months,  we  must  assimie  that  it  is  a  mixed  tumour 
which  has  become  secondarily  nialigiianf,  a  not  infrequent  event- 
In  these  cases  the  growth  soon  loses  its  mobility,  and  at  the  operation 
it  cannot  be  shelled  out  as  easily  as  an  innocent  mixed  tumour. 
Primary  malignant  tumours  of  the  gland  are  very  rare,  and  we 
will  discuss  them  in  common  with  those  of  the  parotid. 

On  examining  these  mixed  tumours  a  little  more  closelv,  we 
shall  see  on  section  that  they  are  partly  fibrous,  partly  gelatinous 
and  partly  like  soft  cartilage.  Histologically  they  consist  of  a  richly 
cellular  tissue  in  which  there  are  regularly  arranged  strands  of  cells, 
called  by  some  observers  epithelial  cells,  and  by  others,  with  equal 
confidence,  endothelial  cells.  In  addition  there  are  numerous  islets 
of   cartilage,  and  areas  which  have  undergone  mucoid  degeneration. 

(b)  Parotid   Region. 

The  considerations  referring  to  the  submaxillary  region  hold  good 
for  the  parotid  region,  but  here  the  differential  diagnosis  is  more 
limited  in  one  respect,  although  more  extensive  in  another.  Fibroma 
does  not  occur  and  chronic  inflammatory  processes  which  look  like 
growths  have  not  been  observed  in  the  parotid,  with  the  exception  of 
the  diffuse  swellings,,  which  have  been  described  in  syphilis.  But, 
on  the  other  hand,  there  is  the  possibility  of  confusing  tubercular 
glands  with  a  new  gi-owth.  It  is  easy  to  avoid  this  confusion  in  the 
submaxillary  region,  because  the  tubercular  glands  are  multiple  and 
can  be  felt  separately.  In  the  parotid  region,  however,  there  are  small 
lymphatic  glands  within  the  capsule  of  the  salivary  gland,  and  when 
these  become  tubercular,  they  gradually  lift  up  the  capsule,  still  being 


i68 


SURGICAL   DISEASES   OF   THE   NECK 


confined  within  its  limits.  It  may,  therefore,  be  quite  impossible  to 
feel  the  individual  glands  as  separate  structures,  because  they  con- 
stitute as  it  were  a  common  growth  within  the  capsule.  The 
presence  of  other  glands  in  other  situations  of  the  neck  might  of 
course  lead  us  to  think  of  tubercle. 

A  female  of  healthy  antecedents,  aged  30,  consulted  her  family 
doctor  because  of  a  swelling,  elastic  in  consistence,  which  was 
gradually  making  its  appearance  in  the  parotid  region.  Lower  down 
in  the  neck  there  were  a  few  soft  glands,  apparently  deeply  situated, 
but  not  adherent  to  their  surroundings.  The  facial  nerve  was  un- 
affected  and    there  was  no  pain.      Everything  pointed  to  tubercular 

glands    rather     than    to    a 
_  growth.     But  the  shape  of 

[  the    tumour,    which    corre- 

sponded    to     that    of    the 
parotid     gland,      including 
even  its   posterior  process, 
behind    the    lobule  of    the 
ear,    looked    startling    and 
made   one  think  of  a  new 
growth.      Nevertheless    the 
operation  showed   that  the 
case  was  one  of  tubercular 
glands  ;    they    were    as    if 
moulded  within  the  parotid 
capsule,    and     the    parotid 
tissue  itself  was  entirely  dis- 
placed irito  the  deeper  parts. 
Tuberculosis  of  the  glan- 
dular substance  itself,  which 
is    a   rare    condition,  must 
be     distinguished    from 
;     tubercle    of    the    lymphatic 
j     glands  over  the  parotid.     If 
I     the  patient  is  not  tubercular 
and    there    is    no    chronic 
abscess    present    to    give  a 
clue,  it    is    hardly   possible 
to  make  the  diagnosis.     At  any  rate,  we  are  not  able  to  differentiate  it 
clinically  from  tubercle  of  the  lymphatic  glands  over  the  parotid. 

If  we  have  excluded  tubercular  disease,  the  innocent  tumours 
which  remain  are  the  mixed  tumour,  described  in  connection  with 
submaxillary  gland,  and  pure  enchondromata,  which  are  rare.  The 
mixed  tumours  of  the  parotid  are  so  typical  of  new  growths,  that 
no  mistake  can  be  made  in  their  diagnosis,  even  if  they  do  not 
present  those  grotesque  shapes  which  used  formerly  to  be  seen. 
Every  m(jvable  irregular  nodular  tumour  of  the  parotid  region  must. 


L. 


Fig.  87. — Mixed  tumour  of  the  parotid. 


TUMOURS    AXD    ALLIED    SWELLINGS    OF   THE    XECK 


169 


at  first,  be  assumed  to  be  a  mixed  tumour,  but  the  question  at  once 
arises,  whether  it  is  still  innocent.  The  absence  of  facial  paralvsis 
and  of  radiating  pains  in  addition  to  its  fiee  mobility  should  be 
conclusive  in  this  respect.  Pure  enchondromata,  apart  from  the 
pre-auricular  skin  appendages  which  contain  cartilage,  are  of  much 
rarer  occurrence. 

We  now  come  to  the  primary  mahgnant  tumours  of  the  sub- 
maxillary and  parotid  region,  whose  chief  symptoms — adhesion  to 
the  surrounding  parts,  especially  to  nerves — we  have  already  noted. 

We  conclude  that  a  case  is  one  oi  primary  sarcoma,  or  carcinoma 
of  the  affected  salivary  gland,  from  the  absence  of  anv  stage  of  long 
duration  which  is  characteristic  of 
an  innocent  tiunour,  and  wliich 
could  hardly  be  overlooked  bv  the 
patient.  Can  we  go  bevo nd  this 
and  distinguish  between  carci- 
noma and  sarcoma  ?  xAs  a  rule  we 
cannot,  because  even  the  histo- 
logical picture  of  salivarv  gland 
tumours  is  variously  interpreted. 
Experience,  however,  teacher  us 
that  cancer  is  more  frequent  in  the 
salivary  glands  than  is  sarcoma. 

It  should  be  added  that  cancer 
does  notalways  exist  in  the  form  of 
a  ''tumour."  The  parotid  is  some- 
times affected  by  a  scirrJioiis  cancer, 
just  as  the  breast,  in  which  con- 
dition the  skin  is  puckered  rather 
than  swollen.  Such  new  growths 
manifest  themselves  early  bv  means 
(jf  radiating  pains,  especially  to- 
wards the  head,  and  also  bv  par- 
alysis, or  paresis   of  some  of  the 

facial  twigs,  if  not  of  the  whole  nerve.  If  such  symptoms  are  present 
we  must  not  neglect  making  a  thorough  examination  of  the  parotid 
region,  although  there  may  be  no  tumour  apparent. 


Fig.  88. — Cancer  of  the  parotid.  The 
lobule  of  the  ear  is  pushed  forwards  by  the 
posterior  process  of  ihe  gland. 


(c)  Side  of  the    Neck. 

We  now  come  to  the  side  of  the  neck  in  the  more  limited  sense. 
As  mentioned  above,  the  innoccni  tumours  in  this  region  are  mostly 
fibromata,  or  ncnro-Jibromata  ;  the  primary  malignant  tumours  are, 
with  two  exceptions,  sarcomata. 

Cancer  of  the  oesophagus  and  trachea  are  not  included  here, 
because  they  are  fatal   before  thev  give  rise  to  any  growth  externally. 


IJO  SURGICAL    DISEASES    OF   THE    NECK 

Cancer  of  the  cervical  portion  of  the  gullet  may  at  times  be  palpable 
from  the  outside,  but  the  difficulty  in  swallowing  is  so  prominent 
a  feature  that  the  site  of  the  disease  is  always  perfectly  clear. 

Fibromata  and  neuro-fibromata  occur  as  slowly  growing,  firm^ 
movable,  spindle-shaped,  or  oval  tumours,  over  which  the  skin  is 
freely  movable.  If  their  origin  is  deep — from  the  sympathetic,  from 
the  pre-vertebral  connective  tissue,  or  from  the  vertebral  column  itself 
— their  position  is  more  or  less  retro-pharyngeal  and  they  cause 
correspondingly  early  symptoms  of  dysphagia  and  even  of  dyspnoea. 
These  tumours  are  frequently  confused  with  fibromata  growing  from 
the  base  of  the  skull  and  with  retro-pharyngeal  abscess.  The  same 
applies  to  fibro-sarcomata,  except  that  these  grow  more  rapidly  and 
are  less  movable.  Even  with  the  microscope  their  distinction  from 
fibromata  on  the  one  hand  and  sarcomata  on  the  other  is  very 
difficult. 

Xeuro-fibromata  have  a  special  tendency  to  become  sarcomatous. 
Often  they  are  only  one  indication  of  a  general  fibromatosis  known 
as  "Recklinghausen's  disease."  Congenital  psychical  abnormalities 
are  often  associated  with  this  disease,  viz.,  imbecility,  infantilism, 
psycho-neuroses.  The  fibromatosis  may  encroach  on  the  central 
organs  and  give  rise  to  the  most  varied  nerve  symptoms. 

Sarcoma  of  the  neck  may  originate  in  any  of  the  connective  tissue 
structures  of  th:s  region,  e.g.,  fascia,  periosteum,  muscular  connective 
tissue,  nerves,  &c.  Its  favourite  seat  is,  hov\-ever,  in  the  lymphatic 
glands,  even  leaving  out  of  consideration  their  enlargement  in 
malignant  lymphoma. 

In  connection  with  lymphatic  gland  sarcoma  it  is  necessar}"  to 
distinguish  between  " lympho-sarcomata  "  and  "sarcomata  of  the 
lymphatic  glands."  The  former  are  sarcomatous  proliferations  of  the 
Ivmphatic  tissue;  the  latter  are  sarcomata  of  the  supporting  tissue. 
The  former  are,  therefore,  round  small-celled  sarcomata,  sometimes 
with  an  interlacing  reticulum;  the  latter  are  mainly  spindle-celled 
sarcomata.  The  difference  is  interesting  from  the  standpoint  of 
pathological  anatomy,  but  it  would  be  too  much  to  expect  that  the 
difference  should  be  detected  from  clinical  signs.  If  the  tumour  is 
definitely  soft  and  the  growth  is  infiltrating,  we  should  suspect 
"  lympho-sarcoma  "  ;  if  it  is  definitely  iiard  it  should  be  regarded  as 
a  "  sarcoma  of  the  lymphatic  glands." 

"Malignant  lymphoma,"  referred  to  above,  must  not  be  confused 
with  these  sarcomata.  The  former  is  a  constitutional  disease,  whereas 
lympho-sarcoma  and  sarcoma  of  the  lymphatic  glands  are  tumours  of 
individual  glands.  Intermediate  forms  have  been  described,  but  these 
are  either  very  malignant  forms  of  "malignant  lymphoma" — with  rapid 
growth  and  surrounding  infiltration — or  "  sarcomata  of  the  lymphatic 
glands"  with  secondary  metastases.  The  whole  subject  is,  however, 
still  in  some  obscurity,  especially  in  regard  to  so-called  lympho- 
sarcomata. 


TUMOURS    AND    ALLIED    SWELLINGS    OF    THE    NECK 


171 


Vasciihiy  sheath  sarcoma  formerly  constituted  a  separate  variety. 
It  is  undoubted  that  sarcomata  may  grow  from  the  sheaths  of  large 
vessels,  but  most  of  the  cases  thus  described  were  really  sarcomata  of 
the  lymphatic  glands.  We  must  be  reconciled  to  the  difficulty  of 
determining  clinically  their  point  of  origin,  especially  as  it  is  usually 
impossible  to  do  so,  even  at  the  operation. 

In  every  case  of  primary  malignant  growth  of  the  neck  the 
question,  whether  it  is  one  of  the  rare  primary  forms  of  carcinoma, 
eventuallv  arises. 

Tumours  have  often  been  found  in  the  upper  part  of  the  side  of 
the  neck,  which  have  been 
demonstrated  by  histological 
examination  to  be  cancers,  with 
stratified  pavement  epithelium 
and  for  which  no  primary  growth 
could  be  found.  Their  origin 
must  therefore  be  ascribed,  as 
Volkmann  suggests,  to  congeni- 
tally  displaced  epithelium  of  a 
branchial  cleft,  or  to  some 
persistent  epithelium  of  this 
rudiment.  If,  in  the  position 
indicated,  and  in  a  man  of 
middle  age,  there  be  a  tumour 
with  the  signs  of  a  malignant 
growth,  especially  if  there  are 
severe  pains  radiating  towards 
the  head  and  back  of  the  neck, 
the  case  is  in  all  probabiHty 
a  branchiogenous  carcinoma. 
Hitherto  these  cases  have  only 
been  noted  in  males. 

In  some  few  cases  it  has  been 
possible  actually  to  demonstrate 
the  transition    of   a    congenital 

cyst,  situated  at  the  side  of  the  neck,  into  a  carcinoma.  ^Malignant 
growths  of  the  parathyroids  may  also  be  regarded  as  branchiogenous 
carcinomata  in  the  widest  sense  of  the  term,  as  also  the  much  rarer 
growths  which  arise  from  the  post-branchial  bodies,  the  so-called 
lateral  thyroid  gland  rudiments. 

On  the  other  hand,  cancer  of  the  accessory  thyroids  are  not  related 
to  the  branchial  apparatus  but  to  the  thyreo-glossal  duct.  An  accurate 
diagnosis  of  this  growth  is  impossible  without  the  microscope. 

There    is    yet    another   tumour,    worth    bearing    in    mind,    which 
occurs  in  the  same  situation  as  the  usual  branchiogenous  squamous 
12 


Fig. 


Branchiogenous  carcinoma. 


172 


SURGICAL   DISEASES    OF   THE   NECK 


epithelial  cancer.  It  is  neither  a  carcinoma  nor  a  sarcoma,  but  a 
structure,  siii  geiiei-is,  just  like  a  hypernephroma.  It  is  a  new  growth 
arising  from  the  carotid  body,  found  in  both  sexes  and  at  very 
various  ages.  It  is  definitely  encapsuled,  and  its  growth  extends  over 
many  years,  thus  exhibiting  a  comparatively  innocent  character.  In 
this  way,  it  shows  a  clinical  differentiation  from  a  branchial  cancer. 
Vessel  walls  are  constantly  observed  to  grow  through,  and  local 
recurrence  frequently  occurs.  It  is  usually  soft  or  elastic  in  con- 
sistence, and  its  close  connection  with  the  carotid  artery  imparts  to 
it  a  pulsatile  movement. 

^Microscopically  this  tumour  is  similar  to  a  normal  carotid  body. 
It  is  composed  of  a  tissue  made  up  of  polvgonal  epithelioid  cells, 
like  the  main  structure,  and  is  traversed  by  blood  spaces  invested  by 
endothelium,  after  the  manner  of  a  sponge. 


fd)  Supra-clavicular  Region. 

The  genuinely  primary  tumours  of  this  region  are  the  rare  deep 
lipomata  as  well  as  fibromata  and  sarcomata.  Cervical  ribs  often 
give  rise  to  errors  of  diagnosis,  and  we  shall  therefore  now  proceed 
to  discuss  them. 

A  cervical  rib  is  a  small  hard  structure  which  can  be  felt   in  the 

s  u  p  r  a-c  1  a  V  i  c  u  lar 
fossa.  Its  exists 
ence  may  give  rise 
to  no  subjective 
symptoms,  but  on 
the  other  hand  it 
may  cause  neural- 
gia or  paresis  of 
the  nerves  of  the 
arm,  and  excep- 
tionally it  ma}'  pro- 
duce circulatory 
disturbances  in  the 
subclavian  artery. 

Sometimes  these 
symptoms  of  pres- 
sure on  the  nerve 
plexus  or  on  the  ar- 
tery only  supervene 
after  some  definite 
cause.  Thus  I  have 
seen,  in  a  soldier  with  a  cervical  rib,  complete  obliteration  of  the 
radial  pulse  from  the  effect  of  the  leather  strap  of  his  knapsack. 


1 

j 

4 

H.n 

H__^^H 

ay 

jun 

^^^^&^'               vl 

£1-: 

^^IHJI^'^ .  A 

Right. 


Left. 


Fig.  90. — Bilateral  cervical  ribs.  On  the  right,  a  small  rudi- 
ment C  R  attached  to  the  first  rib.  On  the  left,  a  larger  rib  which 
is  continued  to  the  sternum  by  means  of  a  clasp  S.  R  1 — /// 
indicate  1st,  2nd,  and  3rd  ribs.  C  V — VII,  D  I — III  &re  placed 
on  transverse  processes  of  cervical  and  dorsal  vertebrae. 


TUMOURS   AND   ALLIED   SWELLINGS   OF   THE   NECK 


^73 


Fig.  91. — Unilateral  lipoma  of  back  of  neck. 


The  subclavian  artery  either 
runs  over  the  rib,  or  in  front 
of  it.  The  abnormality  is 
usually  bilateral,  but  more 
pronounced  on  one  side  than 
on  the  other.  Very  rarely  two 
ribs  ai"e  found  on  the  same 
side,  with  the  subclavian  artery 
running  between  them. 

If  the  medical  attendant 
does  not  bear  in  mind  the 
possibility  of  a  cervical  rib  and 
is  misled  by  the  hardness  of  the 
structure,  he  will  diagnose  a 
malignant  growth  ;  if  he  is 
struck  by  the  pulsation  of  the 
subclavian  artery,  which  is 
pushed  forwards,  he  will  regard 
the  case  as  an  aneurism,  as  the 
foUowijig  instance  illustrates. 
A   middle-aged  male  consulted  his    doctor  in  reference  to  throat 

trouble.     The  latter  found,  after  a  conscientious  examination,  a  small 

pulsating  tumour  in  one  of  the  supra-clavicular  fossae,  and  he  thought 

of  a  subclavian  aneurism.     But  a  closer  investigation  revealed  a  small 

hard  structure  over  which 

the  sub-clavian  artery  ran, 

but     the    artery  was    not 

enlarged — hence  the  con- 
dition was  one  of  cervical 

rib.      The  diagnosis    was 

clearly    confirmed     by    a 

skiagram    (fig.    90).       The 

throat  trouble  was  due  to 

chronic  pharyngitis. 

If   the  hard  resistance 

were  strikingly  great,  one 

\vould  think   of  a    cJioncl- 

roiua   or   ostcoinci    starting 

from   a    cervical    rib.       If 

the      pulsating     structure 

near  or  over  the  cervical 

rib  were   larger   than    the 

circumference  of  a  normal 

subclavian,  one  would  en- 
tertain   the    possibility   of 

an   aneurism  caused  by  a 

cervical  rib. 


Fig.  92. — Symmetrical  lipoma  at  back  of  neck. 
(From  the  Surgical  Clinique  at  Berne.) 


174 


SURGICAL    DISEASES    OF   THE   NECK 


C— THE  BACK  OF  THE  NECK. 

We  shall  conclude  tiie  discussion  of  tumours  of  the  neck  with  the 
new  growths  of  the  posterior  cervical  region. 

A  median,  cvstic,  soft,  elastic  or  fluctuating  tumour  is  usually  a 
meningocele  or  meningo-encephalocele  (fig.  i6);  rarely  a  dermoid. 
The  contents  of  the  first  two  varieties  are  displaceable  on  pressure,  and 
vary  in  tension  according  to  variations  in  cerebral  pressure.  They 
are  usually  found  in  children  only,  because  the  patients  generally 
succumb  unless  successfullv  operated  on.  But  dermoids  are  found 
at  a  later  age  also,  as  well  as  superficial  sebaceous  cysts. 

Apart  from  these,  the  most 
frequent  tumours  in  this  region 
are  lipomata.  If  the  structure 
is  lobulated,  soft  in  consist- 
ence, single,  and  laterally 
situated  (fig.  91),  it  is  an 
ordinary  encapsiiled  lipoma^ 
which  can  be  shelled  out  with 
the  greatest  ease.  If,  on  the 
other  hand,  there  are  two  tu- 
mours, symmetrical^  placed 
near  the  middle  line,  which 
are  not  detinitely  lobulated 
but  rather  nodular  and  hard,. 
with  no  tendency  to  become 
pendulous,  the  diagnosis  is 
sxmiuetricciJ  posterior  cervical 
lipoma,  a  condition  which 
occurs  especially  among  dis- 
ciples of  Bacchus.  Frequently 
these  tumours  are  accom- 
panied by  another  pair,  situ- 
ated lower  down  (fig.  92). 
Beginners  should  be  warned  that  the  removal  of  these  tumours 
should' not  be  lightly  undertaken.  They  dip  in  between  the  interstices 
of  the  muscles,  and  have  extensive  adhesions,  so  that  the  operation  is 
very  troublesome  and  apt  to  be  attended  by  severe  haemorrhage. 

Peri-glandular  lipoma  is  a  third  form  of  lipoma,  which  occurs  not 
only  at  the  back  of  the  neck,  but  also  in  other  situations  of  the  neck 
and  bodv  generally,  as  circumscribed  accumulations  of  fat  around 
lymphatic  glands  (fig.  93). 

Diffuse  lipoma  of  the  neck,  as  described  by  Madelung,  must  be 
distinguished   from    the    ordinary    symmetrical    lipoma   of   the    back 


P'iG.  93.  —  Peri-glandular  lipoma. 
(From  the  Surgical  Clinique  of  Eerne. 


ABNORMAL    POSTURES    OF   THE    HEAD  1 75 

of  the  neck.  The  whole  neck  is  surrounded  by  a  fatty  mass,  as  by 
a  coHar,  out  of  which  the  head  appears  to  emerge. 

Probably  the  two  latter  forms  of  lipoma  have  some  connection 
with  adiposis  dolorosa  or  Dercimi's  disease.  This  disease  is  recognized 
by  the  distribution  of  nodular  or  diffuse  masses  of  fat  in  different 
parts  of  the  body,  associated  with  severe  pain  on  pressure,  neuralgia, 
and  other  sensory  disturbances.  Certain  clinical  and  anatomical 
findings  suggest  a  connection  between  this  disease  and  functional 
disturbances  of  the  thyroid  or  pituitary  gland  (see  p.  24). 

Hard  tumours,  mostly  situated  at  the  side  of  the  posterior  cervical 
region,  are  either  fibromata  or  sarcomata.  They  may  arise  from 
the  aponeurotic  connective  tissue,  more  rarelv  from  the  vertebral 
spine,  but  sometimes  even  from  the  skin.  The  rapidity  of  its,  growth, 
its  adhesions,  its  consistence  and  the  condition  of  the  superjacent 
skin  will  indicate  whether  the  growth  is  more  fibromatous  or  more 
sarcomatous  in  nature,  or  Avhether  it  is  a  pure  sarcoma. 

A  very  rare  case  is  recc^rded  by  Dower.  This  was  a  fibroma  of 
the  dura  mater  with  a  slender  peduncle,  which  made  its  way  between 
the  second  and  third  cervical  vertebrae,  and  formed  an  orange-sized 
tumour  at  the  side  of  the  neck.  The  main  feature  of  the  case  was 
the  compression  of  the  spinal  cord.  A  very  similar  case  was  success- 
fully operated  on  by  Wilms. 


CHAPTER  XXV. 

ABNORMAL    POSTURES    OF    THE    HEAD. 

It  is  said  that  a  politician  once  felt  much  encouraged  durmg  the 
delivery  of  a  long  speech  by  the  remarkabh^  attentive  posture  of 
his  immediate  neighbour  in  the  audience.  He  thanked  the  listener 
after  the  speech,  but  the  latter,  not  quite  appreciating  the  gratitude, 
said  he  had  a  stiff  neck.  Obviously  the  speaker  was  not  a  medical 
practitioner.  IIV  infer  from  a  stiff  neck  something  quite  different 
to  special  attentiveness. 

We  must  first  note  whether  the  patient  carefully  avoids  any  move- 
ment of  the  head  for  fear  of  pain,  or  whether,  although  he  holds 
the  head  in  an  abnormal  position,  he  is  able  to  move  it  partially 
without  pain. 

A.— PAINFUL    RIGIDITY    OF    THE    NECK. 

Every  painful  condition  about  the  neck  has  the  efi'ect,  on  the 
cervical    vertebrcC.   which   we   call    muscular   tixation  when    it    occurs 


176 


SURGICAL   DISEASES   OF   THE   NECK 


in  otlier  joints.  A  boil  at  the  back  of  the  neck  suffices  to  produce 
this  effect.  The  nature  of  the  case  is  evident  as  soon  as  we  see  the 
patient  coming  with  a  compress  on  his  neck  or  a  plaster  applied. 
There  is  no  need  for  the  patient  to  state  his  case  ;  but  the  underlying 
cause  of  the  condition  may  be  difficult  to  ascertain.  If  the  muscles  on 
both  sides  are  equally  tense  and  the  head  is  held  in  the  middle  line,  we 

may  assume  that  the 
lesion  which  excites 
the  pain  is  centrally 
situated,  whereas  if  the 
head  is  held  asymmet- 
rically the  lesion  is  on 
one  side.  We  shall 
discuss  each  variety 
separately,  because  the 
considei'ations  we 
shall  advance  proceed 
from  the  beginning,  in 
different  directions. 

(1)  SYMMETRICAL 
FORMS. 

As  the  muscular 
causes  which  may  pro- 
duce rigidity  are  gen- 
erally unilateral  and 
therefore  result  in  iviy- 
iieck,  we  should  at  once 
think  of  a  median  struc- 
ture, the  cervical  spines 
when  the  rigidity  of 
the  head  is  in  a  straight 

posture.     But  even  then,  our  conception  of  the  case  will  vary  with 

the  sudden  or  gradual  character  of  the  onset. 


Fig,  94. — Complete  forward  dislocation  of  the  5th  ceivical 
vertebra  on  the  6lh.     Compare  fig.  96. 


(a)   Rigidity  with   Sudden    Onset, 

If  the  rigidity  has  come  on  suddenly,  we  first  enquire  about  an 
injury.  In  cases  of  severe  injury  to  the  cervical  vertebras,  the  patient 
supplies  his  own  indications  thereof. 

In  bilateral  or  complete  dislocation,  or  in  fracture-dislocation, 
with  the  dislocation  still  persistent,  the  profile  show^s  significant  dis- 
placement of  the  head  forwards,  usually  associated  with  flexion.  The 
dislocation    always    occurs    in    a    manner   which    causes    the    upper 


ABNORMAL   POSTURES   OF   THE    HEAD 


177 


vertebra  to  project  beyond  the  lower,  and  which,  with  few  exceptions, 
brings  about  sHght  flexion  at  the  same  time. 

We  must  recall  the  actions  of  the  various  parts  of  the  cervical 
spine  in  order  to  test  the  functions  of  the  neck.  The  movement  of 
nodding  occurs  between  the  occiput  and  atlas ;  the  movement  of 
rotation  between  the  atlas  and  axis,  and  lower  down  the  chief  move- 
ment is  that  of  bending  the  whole  neck  backwards  and  forwards. 
It  should  be  remembered  that  the  various  joints  of  the  neck  are  able, 
to  a  great  extent,  to  replace  one  another. 

On  palpation  an  unusual  space  is  to  be  noted  between  two  spinous 
processes.  The  spinous  process  of  the  dislocated  vertebra  is  also 
displaced  upwards,  touching 

the  spine  of  the  next  highest       ' .^^■^^^^^■■■■i  ^T 

vertebra  (fig.  96). 

In  lean  subjects  the  spi- 
nous process  of  the  axis  can 
be  distinctly  felt,  but  those 
of  the  third  and  fourth  verte- 
brae are  indistinct.  The  spine 
of  the  fifth  vertebra  is  again 
distinct,  and  those  of  the 
sixth  and  seventh  are  very 
clearly  felt. 

The  demonstration  of 
displacement  of  the  lateral 
portion  of  the  vertebra  would 
be  of  value  m  diagnosis, 
but  this  is  very  cHfticult.  On 
the  other  hand,  a  widening 
of  the  neck  as  seen  in  profile, 
in  addition  to  bending  of 
the  head,  is  very  significant. 
The  displacement  which  is 
most  common   concerns  the 

fifth  vertebra,  in  relation  to  the  sixth,  wherein  the  spinal  cord 
sometimes  escapes  injury,  as  was  especially  pointed  out  by  Steinmann. 
Complete  dislocations  higher  up  are  nearly  always  fatal.  But  should 
such  a  case  survive,  the  diagnosis  could  be  established  by  feeling 
through  the  pharynx  and  by  external  palpation  of  the  side  of  the 
neck.  But  sometimes  the  displacement  is  very  slight  in  compression 
fractures  (fig.  96),  and  it  is  quite  impossible  to  decide  upon  the  nature 
of  the  injury  merely  by  means  of  palpation.  A  diagnosis  can  only 
then  be  made  by  X-rays.  These  are  the  cases  which  form  the  inter- 
mediate stage  towards  contusion  and  sprain. 

There  is  no  change  in  the  shape  of  the  cervical  spine  in  these 
latter    cases.     Spine   and    lateral    processes   are    in    correct    position. 


Fig.  95. — Fracture-dislocation  between  the  5th 
and  6th  vertebraa,  fixed  in  the  position  of  sub- 
luxation.    {Post-mortem  preparation.) 


1 78 


SURGICAL   DISEASES    OF   THE    NECK 


It  is  only  the  active  movements  which  are  deranged,  and  this  is  quite 
relative.  It  is  caused,  as  previously  explained,  by  muscular  fixation 
induced  by  the  pain.  Careful  and  slow  manipulation  will  not  only 
allow  of  the  performance  of  all  passive  movements,  but  will  also 
permit  of  their  active  performance.  Theoretically  there  should  be 
no  pain  in  a  case  of  sprain  when  pressure  is  made  in  the  long  axis, 
but  it  is  sometimes  present  because,  as  a  consequence  of  the  normal 
curvature  of  the  cervical  spine,  every  thrust  causes  an  increase  of 
dorsiflexion    and    therewith  some  tearing  of  the  ligaments.     If  such 

pressure  is  very  pain- 
ful it  suggests  con- 
tusion of  an  inter- 
vertebral disc,  or  even 
a  fracture  unaccom- 
panied by  dislocation. 

On  the  other  hand, 
the  pain  caused  by 
pressure  in  the  long 
axis  in  cases  of  severe 
contusion  and  com- 
pression fracture,  is 
sometimes  less  than 
might  a  priori  be  an- 
ticipated. 

Pressure  on  the 
spinous  process  may 
also  be  painful  in  cases 
of  sprain,  because  it 
may  produce  slight 
displacement  and  tear- 
ing of  the  injured  liga- 
ments. 

The  site  of  the 
sprain  ma}- be  inferred 
from  the  character  of 
the  disturbed  functions  and  from  the  position  of  the  pain.  If  the 
nodding  movement  is  affected,  but  the  neck  can  still  be  bent,  the  injury 
exists  at  the  occipito-atlantal  joint.  If  there  is  difficulty  in  turning  the 
head  the  sprain  is  probably  between  the  atlas  and  axis.  If  the  power 
of  bending  backwards  and  forwards  is  involved  the  sprain  is  more 
deeply  situated.  Very  careful  observation  is  required  to  distinguish 
between  nodding  movements  and  bending  of  the  neck,  but  this  differ- 
entiation can  be  made  out  quite  accurately.  The  existence  of  damage 
to  the  spinal  roots  (neuralgias)  is  also  of  value  for  the  diagnosis. 

The   foregoing   remarks   require  some   amplification.      There    are 


Fig.  96.— Complete  forward  dislocation  of  5th  cervical 
vertebra.     Compare  with  fig.  94. 


ABNORMAL   POSTURES   OF   THE   HEAD 


179 


Fig.  97. — Normal  vertebra  taken  with  mouth  widely  open,     a,  Joint 
between  atlas  and  axis  ;  b,  odontoid  process  of  axis. 


some  injuries  of  the  first  two  cervical  vertebrae  which  cause  no  striking 
alteration  of  posture,  but  produce  very  severe  pain  on  movement  and 
a  corresponding  muscular  fixation.  Fractures  of  the  first  two 
vertebras  are  immediately  fatal   if  combined  with   definite  dislocation, 

but  if  not  so 
complicated 
they  may  re- 
cover, unless 
some  unfore- 
seen movement 
or  careless 
e  X  a  m  i  n  a  t  i  o  n 
causes  a  dislo- 
cation as  a  sup- 
plementary in- 
jury. A  case  of 
this  kind  is  re- 
corded wherein 
the  patient  died 
suddenly  as  the 
nurse  was  help- 
ing  to    sit    him 

up.  These  patients  are  constantly  holding  their  head  with  their  hands, 
because  they  feel  very  uncertain  about  hs  stability.  The  fracture  is 
either  in  the  arch  of  the  atlas  or  axis,  or  in  the  odontoid  process  of 
the  latter.  A  fairly  accurate  diagnosis  can  only  be  made  in  the  former 
condition,  if  by  examination  through  the  mouth  of  the  palpable  portion 
of  the  atlas  it 
is  possible  to 
detect  any  dis- 
placement or 
abnormal  mo- 
b  i  1  i  t  y  .  No 
other  diagnostic 
manipulation 
ought  to  be 
undertaken  if 
there  be  any  sus- 
picion of  such 
a  severe  injury. 
But  it  is  permis- 
sible to  take  an 
X-ray  picture 
(from  the  side 
and  from  the 
front    with    the 

mouth  open)  as  long  as  the  process  can  be  carried  out  with  the 
necessary  care. 

Fractures  of  the  odontoid  process  cannot  be  diagnosed  clini- 
cally, but  they  can  be  shown  on  a  skiagram  of  the  first  vertebra,  if 
taken  with  the  mouth  widely  open  (figs.  97  and  98), 


Fig.  98. — Fracture  of  odontoid  process,  taken  through  the  mouth. 
The  two  articular  surfaces  between  alias  and  axis  are  united  by  line 
of  fracture. 


i8o 


SURGICAL    DISEASES   OF   THE   NECK 


It  IS  not  very  easv  to  distinguish  partial  fractures  of  the  lower 
cervical  vertebrse  without  displacement,  from  sprains.  Detachment 
from  the  articular  process  with  incomplete  rotation — dislocation,  is 
an  example  of  such  an  injury.  A  long  continuance  of  symptoms, 
assumed  to  be  due  to  a  sprain,  is  strongly  suggestive  of  this  lesion, 
but  a  decision  can  onh'  be  arrived  at  by  a  skiagram. 

A  patient  in  whom  sudden  rigidity  of  the  neck  comes  on,  is  not 
always  aware  of  an  antecedent  injury.  "Torticollis"  is  looked  upon 
very    much    like    "  lumbago,"    and    there    is    always   a    tendency  to 

discover     a    chill    as     its 
cause. 

But  the  real  cause  may 
be  a  slight  twist  just  as  in 
manv  cases  of  lumbago. 
It  is  brought  about  by 
some  fortuitous  movement 
of  the  neck,  in  which  there 
has  been  neglect  to  fix  the 
individual  vertebree  in  the 
necessary  manner  by  ap- 
propriate muscular  action. 
Sometimes  pains  radiating 
towards  the  shoulders  oc- 
occur,  as  in  the  case  of  the 
more  severe  sprains.  But 
none  of  the  spinous  pro- 
cesses are  definitely  pain- 
ful on  pressure,  nor  is  pres- 
sure along  the  axis  of  the 
spine  painful.  Those  who 
have  themselves  suffered 
from  this  kind  of  sprain 
are  best  able  to  appreciate 
its  true  nature. 

In  some  cases  wherein 
the  head  is  held  fixed 
in  a  symmetrical  position  the  cause  is  a  slightly  acute  cervical  adenitis 
due  to  sore  throat. 

If  there  has  been  no  injury  and  the  symptoms  of  rigidity  are 
accompanied  by  rigors  and  fever,  we  must  think  of  the  possibility  of 
osteo-myelitis  of  the  spine.  Active  movements  in  the  adjacent 
vertebral  joints  are  in  abeyance,  there  is  pronounced  pain  on  pres- 
sure over  the  spine  and  lateral  portions,  and  if  the  disease  is  situated 
high  up,  pressure  through  the  pharynx  demonstrates  pain  on  the 
anterior    surface    of    the    vertebra.      Pressure   along   the  axis    of    the 


Fig.  99. — Caries  of  5ih  and  6lh  cervical  veitebrDe. 
Head  displaced  slightly  forwards.  Neck  abnormally 
wide  in  profile. 


ABXOKMAL   POSTURES   OF   THE    HEAD  l8r 

Spine  is  painful,  corresponding  to  the  extent  of  the  inflammation. 
The  diagnosis  would  be  confirmed  if  the  history  revealed  any  recent 
acute  inflammatory  disease  which  might  serve  as  the  primary  focus. 
Further  confirmation  is  afforded  by  the  course  of  the  disease,  in  which 
nerve  root  and  spinal  cord  symptoms  supervene,  and,  unfortunately^ 
by  the  almost  invariably  fatal  termination. 

I  have  seen  osteo-mvelitis  of  this  kind  in  a  man  aged  71,  which 
came  on  as  a  sequel  of  a  mild  pneumonia. 


(b)   Rigidity  with  Gradual   Onset. 

If  the  rigidity  has  come  on  gradiuiUy  the  cause  is  usually  tubercu- 
losis of  the  vertebrje  (fig.  99),  or  more  rarely  a  new  growth.  The 
examination  must  be  conducted  most  carefully,  because  any  excessive 
diagnostic  zeal  may  be  rewarded  by  the  breaking  off  of  the  odontoid 
process  of  the  axis — an  accident  which  has  actually  occurred.  We 
ascertain  the  extent  of  active  movements,  the  amount  of  pain  on 
pressure  oyer  the  long  axis  of  the  spine,  and  on  the  spinous  processes, 
and  finally  we  test  sensitiyeness  to  pressure  through  the  pharynx.  We 
diagnose  the  site  of  the  lesion,  just  as  we  do  the  site  of  an  injury  by 
means  of  the  disturbance  of  movement,  the  change  in  shape  of  the 
spine,  and  by  the  situation  of  the  severest  pain  on  pressure.  Sharply 
limited  neuralgias  often  facilitate  the  local  diagnosis.  We  should  also 
look  for  burrowing  abscesses,  and  test  the  patellar  reflexes  in  order 
to  not  overlook  the  commencement  of  some  pressure  on  the  spinal 
cord  in   the  neck. 

Further  information  is  given  in  the  chapter  on  *'  Inflammatory 
Diseases  of  the  Spinal  Column.'' 

(2)  ASYMMETRICAL  FORMS. 

If  the  posture  of  the  head  is  not  symmetrical,  but  is  inclined 
towards  one  side  and  turned  towards  the  other,  the  condition  is  one 
of  "  wry-ncch."  If  this  has  come  on  suddenly,  the  question  of 
myositis  should  immediately  arise.  This  diagnosis  would  be  borne 
out,  if  a  muscle,  especially  a  sterno-mastoid,  were  not  only  tense  but 
also  swollen  and  painful  on  pressure.  If  the  malady  follows  an  acute 
infectious  disease,  oi"  if  it  is  only  one  manifestation  of  multiple  myositis 
with  high  temperature,  the  condition  is  really  serious,  because  it  may 
lead  to  a  permanent  wry-neck,  through  subsequent  fibrous  degenera- 
tion of  the  muscle.  But  if  there  are  no  seyere  symptoms  and  the 
swelling  of  the  sterno-mastoid  is  the  solitary  morbid  symptom,  we 
may  regard  the  case  as  one  of  rlicuiiuitic  myositis  and  give  a  fayourable 
prognosis. 


l82 


SURGICAL   DISEASES   OF   THE    NECK 


Many  cases  which  are  called  rheumatic  myositis  are  really  due  to 
acute  adenitis  of  a  cervical  gland  lying  beneath  the  sterno-mastoid, 
and  careful  examination  will  often  reveal  some  dental  trouble  or  sore- 
throat  as  the  primary  cause. 

If  the  muscle  is  not  swollen,  but  some  injury  has  preceded  the 
rigidity,  the  case  is  probably  one  of  a  simple  sprain,  which  we  shall 
be  able  to  distinguish  from  a  more  serious  accident  by  means  of  the 
rules  previously  given.  The  more  serious  one-sided  injuries  in  this 
situation  are  usually  one-sided  dislocations.  The  head  is  held  in 
such  a  distinctive   manner  in   these  cases,  that  the  diagnosis  presents 

no  difficulty.  The  head 
is  bent  towards  the 
dislocated  side  and 
turned  towards  the  un- 
injured side  (fig.  lOo). 
At  any  rate  this  is 
the  posture  assumed 
in  cases  of  one-sided 
dislocation  with  inter- 
locking of  the  articular 
processes,  when  the 
articular  process  of  the 
upper  vertebra  has  be- 
come displaced  to  the 
front  of  the  corre- 
sponding process  of 
the  lower  vertebra 
(figs.  102  and  104). 
But  if  the  twist  has 
onlv  proceeded  half- 
wav,  that  is  to  say, 
that  the  articular  pro- 
cess of  the  displaced 
vertebra  rests  on  the 
edge  of  the  process 
of  the  lower  vertebra 
(fig.  103),  we  should 
expect,  theoretically,  that  the  head  would  assume  a  different  posture. 
The  head  should  be  inclined  towards  the  uninjured  side,  so  that  the 
injured  side  would  be  lengthened  and  only  slightly  turned.  This 
variety  of  dislocation  is,  how^ever,  so  unstable,  and  carries  with  it  so 
little  risk  to  life,  that  it  has  never  been  demonstrated  post  mortem. 
Only  a  skiagram  could  show  whether  such  a  picture,  as  conceived  by 
most  writers,  represents  the  truth.  We  might  suspect  this  form  of 
dislocation,  clinically,  in  a  case  wherein  the  amount  of  turning  was 
insignificant  in  comparison  to  the  bending,  and  where  the  spmous 
process  and  lateral  portion  were  only  slightly  displaced.  The  much 
more  frequent  cases  of  complete  rotation-dislocation  with  detachment 
of  an  articular  process  can  likewise  only  be  diagnosed  by  a  skiagram. 


Fig.  100. 


-Left-sided  dislocation  between  atlas  and  axis, 
rotation  of  head  to  opposite  side. 


ABNORMAL   POSTURES   OF   THE    HEAD  l8'> 

As  in  the  case  of  other  dislocations,  the  faulty  position  in  the  neck 
can  be  increased  artificially,  whereas  considerable  resistance  is  offered 
to  opposed  iiwvenieiit,   especially  when   there    is   interlocking.     Spon- 


>^^*? 


.-ff 


Fig.    ioi.  — Complete  dis- 
location. 


Fig.    I02. — One-sided    disloca- 
tion with  inteilocking. 


Fig.   103. — One-sided  dislo- 
cation without   interlocking. 


Fig.  104. — One-sided  dislocation 
with  interlocking. 


taneous  pain  is  often  quite  trifling,  but  in  recent  cases  all  moveuiaits 
for  the  purpose  of  cxainiiiation,  as  well  as  pressure  on  the  spine  of  the 
dislocated  vertebra,  are  painful,  not  always  because  of  the  dislocation, 


1 84 


SURGICAL   DISEASES    OF   THE    NECK 


but,  as  Kocber  remarks,  because  of  the  twisting  of  the  non-dislocated 
side  ;  palpation  affords  the  most  feasible  proof  of  dislocation.  The 
spines  of  the  upper  vertebrae  cannot  ahvays  be  distinctly  felt,  so  that 
we  must  examine  through  the  pharynx  and  endeavour  to  make  out 
whether  we  can  detect  a  lateral  portion  forwardly  displaced.  Any 
kind  of  asymmetry  is  abnormal.  If  we  are  not  quite  sure  about  our 
results,  we  must  examine  with  the  index-finger  of  the  other  hand  for 
the  purpose  of  control.  In  this  way  it  is  quite  possible  to  recognize 
dislocation   of   the   first  two  vertebrae,  and   of  the  third  vertebra  also 

if  the  examining  fin- 
gers are  long  enough 
and  the  patient's  neck 
not  too  long. 

An  examinerwith 
specially  long  fingers 
has  been  able  to 
reach  as  far  as  the 
sixth  vertebra  in  a 
patient  with  a  short 
neck.  This  may  be 
possible  in  toothless 
corpses,  but  not  in 
living  persons. 

On  the  other 
hand,  no  reliable 
results  are  yielded  by 
the  palpation  of  the 
spinous  processes 
and  the  lateral  por- 
tions in  cases  of  rota- 
tion-dislocation. 

Spinal    caries 
must    be    mentioned 
among  the  causes  of 
.,  1  .    .•    11V  painful  wrv-neck.    If 

Fig.    105. — Congenital  torticollis.  r^  ■' 

the  damage  is  only 
on  one  side,  it  may  imitate  the  signs  of  a  one-sided  dislocation,  or 
rather,  it  may  lead  to  that  condition. 


B._PAINLESS  RIGIDITY  OF  NECK. 

It  will,  of  course,  be  understood  that  these  cases  are  always 
chronic.  A  symmetrical  rigidity  must  be  due  either  to  some  form 
of  painless  spinal  caries,  to  an  old  bilateral  dislocation,  or  to  a  healed 
compression-fracture.  But  if  the  condition  is  one  of  wry-neck  and 
an  old  unilateral  dislocation   can    be  excluded  by  palpation,  the  case 


ABNORMAL   POSTURES   OF   THE    HEAD 


i8; 


must    be    grouped    under    the    extensive    class    of    so-called    caput 
obstipum  or  muscular  torticollis. 

The  causation  of  this  common  malady  is  still  a  subject  of  contro- 
versy. Stromeyer  and  many  others  attribute  it  to  injury  of  a  sterno- 
mastoid  during"  birth,  with  subsequent  fibrous  dei^eneration  and 
contraction  of  the  muscle.  Petersen's  view  is  that  the  condition  is 
of  intra-uterine  origin,  due  to  the  cramped  space.  He  bases  his  view 
on  the  cases 
which  are  un- 
doubtedly con- 
genital  and 
even  heredi- 
tary. This  con- 
ception is  con- 
fi  r  m  e  d  b  y 
recent  observa- 
tions (Voelker), 
because  it  has 
been  shown 
that  the  shoul- 
der pressing 
against  the 
neck  ///  iitcro 
leads  to  atro- 
phy of  the 
sterno-mastoid. 
Kader,  how- 
ever, as  a  result 
of  definite  ob- 
servations, at- 
tributes all  wry- 
necks to  the 
result  of  iiifec- 
iivc  myositis, 
which  comes 
on  after  birth, 
but  very  fre- 
quently owing 
to  trauma  dur- 
ing birth.  According  to  Mikulicz,  this  explanation  would  account  for 
iiitm-nteriiie  shortening  of  the  sterno-mastoid. 

However  this  may  be,  the  chief  factor  in  diagnosis  lies  in  the 
circumstance  that  the  malady  has  appeared  during  infancy.  This 
explains  the  fact  that  the  whole  skeleton  has  become  adapted  to  the 
abnormal  posture  of  the  head.  The  skull  is  asymmetrical,  shortened 
and  widened  on  the  affected  side,  the  spinal  column  shows  cervical 
scoliosis  with  a  continuation  thereof  in  the  dorsal  region,  the  convexity 
being  towards  the  healthy  side.  Sometimes  there  is,  in  addition  to 
the    cervical    scoliosis,    a    dorsal    scoliosis    towards  the  opposite   side 


Fig.   io6. — Spastic  torticollis. 


l86  SUKGICAL   DISEASES    OF   THE   NECK 

and  lumbar  scoliosis  towards  the  same  side  as  the  cervical  scoliosis. 
The  one  sterno-mastoid  in  the  neck  is  shortened,  resembling  a  narrow, 
hard,  projecting  band,  whereas  the  other  is  often  abnormally  well 
developed.  The  most  striking  thing  about  the  posture  of  the  head, 
especially  in  children,  is  the  inclination  of  the  neck  towards  the 
affected  side,  with  comparatively  slight  rotation  towards  the  healthy 
side  (tig.  10^).  As  the  disease  progresses  this  lateral  inclination 
of  the  head  diminishes  but  the  rotation  increases,  so  that  the  head 
may  deviate  entirely  towards  the  healthy  side.  The  complicated 
vertebral  curvatures  also  belong  to  this  latter  category. 

There  is,  finally,  another  clinical  picture,  which  essentially  belongs 
to  the  department  of  medicine,  but  which  often  appeals  to  surgery 
when  therapeutic  measures  have  failed. 

As  soon   as  the  patient  begins   to    describe   his   malady — which, 
however,  is  c|uite  unnecessary — his  head  is   suddenly   and   violently 
jerked  to  one  side  and  turned  towards  the  other.     The  more  excited 
he  becomes  thereby,  and  the  more  anxious  he  is  to  impress  us  with 
his  distressing  condition,  the  more  frequent  become  these  spasmodic 
movements.     Sometimes  the  facial  muscles,  the  muscles  of  the  floor 
of   the    mouth  and  even  the  shoulder   muscles    co-operate    in    these 
convulsive  movements.     They  are  sometimes  intermittent  and  clonic, 
at   other   times  persistent   and   tonic,    involving  not  merely   isolated 
muscles,  but  muscles  which  work  co-ordinately,  and  muscle  groups 
on  both  sides.     For    this    reason    the    older    designation    of    "  spinal 
accessory  convulsions  "  is  incorrect.     The  clinical  picture  represents 
spastic  torticollis  in  its  most  usual  form,  wherein  one  sterno-mastoid 
and  the  posterior  cervical  muscles  of  the  opposite  side  act  together. 
There  are  other  allied  forms  such  as  bi-lateral  contractions  of  the 
muscles  which  bend  the  head,  nodding  spasms  and  the  contractions 
of  the  posterior  cervical  muscles — the  '' retrocollis  spasm  "  of  English 
authors.     There    are    some    patients    who    experience    the    greatest 
difticulty    in    putting   food  in  their  mouths  owing  to  these   spasms. 
I    know   a   practitioner   in    whom   the  disease  started  in   the  form  of 
a   writer's    cramp    in  the  right  arm,  and  as  the  malady   progressed 
the  shoulder  muscles  participated  in  the  spasmodic  movements  of  the 
head.     No   wonder,    then,    that   these   patients    turn    to  the   surgeon 
for  relief  when  internal  treatment  has  failed. 

It  is  still  uncertain  whether  the  situation  of  the  disease — which 
must  be  looked  upon  as  a  neurosis — is  exclusively  in  the  cerebral 
cortex  or  also  in  the  more  deeply  placed  centres  of  co-ordination. 
Possibly  both  are  involved.  At  any  rate  it  is  quite  certain  that  the 
results  of  operative  treatment,  division  of  the  muscles  which  take 
part  in  the  convulsions,  cannot  be  attributed  to  pure  suggestion. 
It  is  more  probable  that  the  irritable  cortical  centre  is  put  out  of 
action  for  a  considerable  time  owing  to  the  absence  of  centrifugal 
impulses  from  the  tense  muscle,  and  thus  repose  is  ensured  for  it. 


PART   III. 
SURGICAL  DISEASES  OF  THE  THORAX. 


CHAPTER  XXVI. 
FRACTURES    OF    THE    BONES    OF    THE    THORAX. 

It  is  obvious  that  the  ribs  may  be  fractured  by  means  of  severe 
violence,  directly — at  the  site  whereon  the  force  is  applied — or 
indirectly  at  the  site  where  the  curvature  is  most  pronounced.  But 
it  is  not  cjuite  so  easy  to  appreciate  that  a  rib  may  break  when  the 
violence  is  very  slight,  or  even  as  a  result  of  muscular  contraction 
only.  Such  cases,  however,  presuppose  a  debilitated  osseous  system 
through  one  cause  or  another,  mostly  senility.  I  knew  an  old  man 
who  fractured  a  rib  through  cutting  a  loaf.  Ribs  have  been  broken 
during  labour  through  muscular  contraction,  and  even  while  sneezing. 
After  a  severe  injury,  in  which  several  ribs  have  been  broken,  it  may 
be  quite  possible  to  hear  crepitus  with  each  breath,  even  in  an  adjoin- 
ing room,  but  in  the  slight  cases  just  mentioned  it  is  often  necessary 
to  search  for  the  injury  in  order  to  make  an  accurate  diagnosis. 

The  outstanding  symptom  is  pain  felt  as  each  breath  is  drawn, 
pain  which  effectually  prevents  any  deep  inspiration.  Gaping, 
sneezing  and  laughing  are  particularly  painful,  and  it  was,  therefore, 
a  thoughtless  joke  on  the  part  of  a  medical  student  who  sent  a 
colleague  suffering  from  fractured  ribs  an  amusing  newspaper  article 
to  cheer  him  up,  the  perusal  of  which  brought  into  play  all  the 
muscles  required  for  a  hearty  laugh.  The  interference  with  respiration 
is  not  necessarily  the  result  of  a  fractured  rib  ;  it  may  be  due  to  a 
hcematoma  in  the  muscle  or  beneath  the  pleura.  Both  these  con- 
ditions are,  however,  very  frequent  in  cases  of  fractured  ribs. 

If,  on  palpating  the  ribs,  we  feel  or  hear  crepitus  anywhere  on 
deep  respiration,  there  can  be  no  doubt  about  fracture.  The 
stethoscope  may  be  of  assistance  in  this  examination.  But  some- 
times we  only  find  a  very  painful  spot  without  any  signs  of  ab- 
normal mobility.     This  may  indicate  nothing  but  a  contusion.     The 

13 


SURGICAL   DISEASES   OF   THE   THORAX 


distinction  is  made  by  the  possibility  or  impossibility  of  eliciting  pain 
indirectly  by  making  pressure  and  counterpressure  on  both  extremities 
of  the  ribs,  i.e.,  by  increasing  their  curvature.  Pain  produced  in  this 
way,  remote  from  the  points  of  pressure,  is  significant  of  fracture  or, 
at  any  rate,  of  incomplete  fracture  of  a  rib. 

If  this  examination  elicits  pain,  both  in  the  back  and  in  the  front, 
it  follows  that  the  rib  has  been  broken  behind  as  well  as  in  front, 
a  frequent  incident  in  contusions  of  the  whole  thorax.  In  these 
cases  there  is  usually  concomitant  damage  to  several  other  ribs. 

Fracture  of  the  sternum  sometimes  runs  its  course  quite  un- 
noticed,  because  the  injury  is  rather  of  the  nature  of  a  fissure  than  a 

complete  fracture 
with  a  b  n  o  r  m  a  1 
movement  and 
displacement.  It 
is  impossible  to 
mistake  this  latter 
form  owing  to  the 
superficial  position 
of  the  sternum. 

The  following 
case  ]-efers  to  an 
unusual  variety  of 
dislocation  : — 

A  w  o  r  k  m  a  n 
fell  against  a  box 
which  he  was  hold- 
ing in  front  of  him, 
in  such  a  way  that 
the  ensiform  pro- 
cess hit  against  its 
edge.  When  the 
patient  undressed 
he  noticed  a  re- 
markable projection  in  the  epigastrium.  The  sternum  had  been  trans- 
A'ersely  split  at  the  level  of  the  fifth  rib,  and  was  displaced  towards  the 
skin.  The  rib  cartilage  was  bent  forwards  and  held  the  displaced 
fragment  so  firmly  in  position  that  reposition  by  the  open  method 
became  necessary  (fig.   107). 

In  cases  where  tfie  accident  is  nothing"  more  than  a  simple 
transverse  fissure,  notice  is  first  attracted  to  the  injury  by  the  ecchy- 
mosis,  which  comes  on  in  the  course  of  a  few  days.  As  stated 
elsewhere,  these  fractures  are  generally  indirect,  and  accompany 
fracture  of  a  vertebra.  It  is,  therefore,  most  important  to  examine 
the  vertebral  column  in  every  case  of  fractured  sternum,  and  vice 
versa. 


Fig.  107. — Fracture  of  the  sternum  with  projection  of  lower 
fragment  externally. 


INJURIES   OB'   THE    LUNG  1 89 

CHAPTER    XXVII. 

INJURIES    OF    THE    LUNG. 

If  a  liquid  effusion  rapidly  makes  its  appearance  within  the  thorax 
of  a  patient  suffering  from  contusion  thereof,  or  from  fractured  ribs, 
we  must  diagnose  Iicviiwrrhngic  effusion,  which  may  originate  either 
from  a  ruptured  intercostal  artery  or  from  the  blood-vessels  of  the 
lung.  We  can  only  be  certain  of  the  latter  origin  if  signs  of  piicinno- 
thorax  supervene  upon  those  of  the  effusion,  or  if  the  patient  conghs 
lip  blood.  The  injury  to  the  lung  becomes  quite  obvious  if  air 
penetrates  into  the  subcutaneous  tissue  and  gives  rise  to  the  well 
known  appearance  of  cellular  einphyseuia,  which  often  extends  over 
a  very  wide  area.  Death  ensues  rapidly  if  a  main  bronchus  has 
been  completely  torn  away  from  the  lung  and  opens  into  the 
mediastinal  ceUular  tissue  and  inflates  it.  The  effusion  of  blood 
and  the  pneumothorax  must  be  carefully  watched,  because  their 
increase,  in  association  with  a  worse  condition  of  the  pulse  and 
respiration,  may  demand  operative  interference.  Sometimes,  how- 
ever, the  initial  symptoms  of  contusion  of  the  lungs  are  so  slight 
that  the  injury  is  overlooked,  and  it  is  only  diagnosed  after  consecutive 
pneumonia  has  arisen. 

Pneumonia,  following  contusion,  usually  appears  within  the  first 
four  days,  a  circumstance  which  is  very  important  in  arriving  at 
a  medico-legal  opinion  in  doubtful  cases. 

Injuries  of  the  pleura  open  to  the  skin  are  of  more  practical 
importance  because  they  demand  rapid  decision  as  to  treatment. 
The  instrument  inflicting  the  injury  is  usually  a  bullet,  knife  or 
dagger,  even  in  times  of  peace. 

The  thorax  has  been  pierced  right  through,  from  axilla  to  axilla, 
by  the  domestic  broomstick,  as  recorded  by  Franke,  with  subsequent 
recovery. 

Gunshot  ivounds  of  the  pulmonary  tissue  are  remarkably  well 
tolerated  because  of  its  great  elasticity.  Recent  wars  have  afforded 
numerous  instances  of  people  shot  through  and  through,  who  kept 
on  marching  or  riding  for  hours,  and  who  returned  to  duty  after 
a  brief  detention  in  the  field  hospital.  This  applies,  at  any  rate, 
to  injuries  inflicted  by  modern  srnall-calibre  bullets  with  their  small 
surface  of  attack.  More  serious  results  follow,  especially  severe 
haemothorax  and  rapid  haemorrhage,  when  shrapnel  bullets  are  used, 
or  when  the  projectile,  on  its  way  through  the  thoracic  wall,  has 
torn  up  buttons  or  splinters  ot  rib.  The  intensely  severe  conditions 
which  result  from  shell  injuries  are  usually  so  obvious  that  diagnostic 
reflections  are  quite  superfluous. 


igo 


SURGICAL  DISEASES    OF   THE   THORAX 


Incised  and  penetrating  wounds  of  the  thorax  cause  expectoration 
of  blood,  whether  the  Iring  is  involved  or  not.  A  simple  haemato- 
thorax  is  not  conclusive  of  the  precise  nature  of  the  injury,  because 
it  may  originate  from  a  wounded  intercostal  or  mammary  artery  as 
well  as  from  a  pulmonary  vessel.  A  pneumothorax  is  only  significant 
of  an  injured  lung  if  the  condition  continues  to  increase  when  the 
external  wound  is  hermetically  sealed. 

We  must  also  be  careful  in  diagnosing  emphysema  in  cases  of 
injurv  to  the  thorax.  Whereas  an  extensive  surgical  emphysema 
points  definitely  to  an  injury  of  the  lung,  the  slighter  forms  are  due 
to  aspiration  of  air  through  the  external  wound  if  the  latter  is  situated 
in  the  vicinity  of  the  armpit,  and  the  patient  is  frequently  lifting 
and  dropping  his  arm. 


Fig.  k 


-Pneumothorax  through  detachment  of  right  bronchus.     Considerable  clear  area. 
Contracted  lung  lying  against  median  shadow. 


In  conclusion,  a  very  important  rule  for  the  examination  and 
treatment  of  injuries  to  the  lung.  Rest  is  of  the  utmost  importance, 
because  every  change  in  position  accelerates  the  respiration  and  may 
cause  a  fresh  haemorrhage.  Diagnostic  energy  must,  therefore,  not 
be  pushed  too  far,  and  we  must  be  satisfied  to  move  the  patient  as 
little  as  possible. 

Although  we  may  be  clear  about  the  injury  to  the  lung,  we  must 
not  forget  that  it  is  often  accompanied  by  secondary  injuries.  The 
diaphragm  and  the  viscera  in  relation  therewith  are  especially  en- 
dangered. A  stab  in  the  right  side  often  involves,  not  only  the  lung 
but  also  the  diaphragm  and  liver.  We  must,  therefore,  never  neglect 
to  examine  for  haemorrhage  within  the  abdomen,  lest  a  patient  may 
be  bleeding  from  a  wound  of  the  liver  while  we  assume  he  has  only 


INJURIES   OF   THE    HEART  191 

sustained  an  injury  to  the  lung,  not  of  a  dangerous  character. 
The  same  consideration  apphes  on  the  left  side,  to  the  spleen.  The 
stomach  is  less  frequently  involved,  because  it  more  easily  escapes 
the  knife  than  the  solid  viscera.  Injuries  to  the  diaphragm  on  the 
left  side  produce  immediate  or  subsequent  diaphraginatic  lieniice. 
The  following  case  shows  that  this  result  is  not  limited  to  penetrating 
injuries  like  gunshot  wounds  or  stabs. 

A  workman  was  brought  to  hospital  in  a  moribund  state  after 
a  severe  crush  of  the  thorax.  The  autopsy  revealed  several  broken 
ribs,  with  a  deep  laceration  of  the  left  lung  caused  by  the  point  of  one 
of  the  rib  fragments.  The  same  fragment  had  pierced  the  diaphragm, 
and  the  wound  therein  was  immediately  filled  up  by  a  fungiform  plug 
of  omentum  which  projected  into  the  pleural  cavity. 

Injuries  to  the  lung  are  sometimes  complicated  by  ivonnds  of  the 
heart,  which  then  demand  the  chief  attention,  as  being  of  the  greatest 
danger.  If  the  injury  involves  the  large  vessels  in  the  mediastinum, 
an  autopsy  is  inevitable.  The  easily  deflected  oesophagus  is  least 
exposed  to  danger. 


CHAPTER   XXVIII. 
INJURIES   OF   THE    HEART. 

TWEXTY  years  ago,  death  from  wounds  of  the  heart  seemed  quite 
the  obvious  thing,  and  recovery  was  ascribed  to  a  lucky  accident. 
Suture  of  the  heart  has  however  now  been  performed  some  dozens 
of  times  and  in  two-fifths  of  the  cases  the  result  has  been  successful. 
But  it  is  necessary  that  the  diagnosis  should  be  made  with  rapidity 
and  accuracy  if  surgical  interfence  is  to  be  afforded  adequate 
opportunity. 

The  position  and  the  character  of  the  wound  are  the  principal 
indications  which  raise  the  suspicion  of  injury  to  the  heart.  Any 
wound  situated  over  the  cardiac  area  or  its  vicinity  should  excite 
suspicion,  and  in  this  connection  it  must  not  be  forgotten  that  the 
heart  may  be  wounded,  in  exceptional  cases,  by  stabs  or  shots  from 
behind.  If  the  wound  is  not  directly  over  the  heart,  the  direction  and 
the  length  of  the  instrument  which  inflicted  it  will  show  whether  it  is 
possible  that  the  heart  may  have  been  involved. 

The  probe  must  never  be  employed  in  examination.  The  only 
reason  for  determining  whether  the  wound  is   a  penetrating  one  is 


192  SURGICAL   DISEASES    OF   THE    THORAX 

to  ascertain  the  presence  of  an  injury  to  any  underlying  organ,  but 
the  probe  is  unable  to  give  information  in  this  type  of  case.  The 
probe  may  actually  impinge  upon  the  heart  and  vet  we  may  be 
unable  to  tell  whether  it  is  injured  or  not.  Beyond  this,  there  is 
an  element  of  danger  in  probing  an  injured  heart,  for  this  procedure 
has  re-started  a  haemiorrhage  which  had  already  ceased.  The  patient 
is  also  unnecessarily  exposed  to  the  risk  of  infection  because  the 
superficial  parts  of  the  wound  are  not  always  aseptic. 

If  the  wound  is  large,  examination  may  be  made  witii  the  finger, 
which  will,  as  a  matter  of  fact,  enable  a  conckision  to  be  arrived 
at  better  than  a  probe,  especially  if  the  finger  not  only  explores 
oz'cr  the  heart  but  also  the  actual  wound  itself,  as  recommended 
by  Longo.  But  we  should  only  resort  to  this  not  entirely  harmless 
examination  when  everything '  is  ready  for  operation  and  our  finger  is 
aseptic. 

in  judging  the  symptoms,  it  should  always  be  remembered  that 
not  all  cardiac  injuries  present  the  same  clinical  picture,  and  that 
not  all  the  classical  signs  appeal"  in  every  case.  The  decision  as 
to  treatment  and  the  framing  of  a  diagnosis  must  therefore  not  be 
delayed  until  all  the  text-book  symptoms  supervene  and  the  patient 
is  moribund. 

The  subjective  sensations  experienced  at  the,  moment  of  the  injury, 
often  referred  to  as  those  of  indescribable  fear,  are  of  significance. 
Rcftex  signs  such  as  fainting  and  vomiting  may  follow  immediately 
on  the  injury,  but  these  must  be  distinguished  from  its  mechanical 
effects,  which  will  be  referred  to  forthwith. 

Apart  from  those  rare  cases  in  which  the  patient  bleeds  externally 
from  his  wound,  there  are  two  distinct  forms  of  cardiac  injury  : 
(i)  in  which  the  pericardium  and  heart  are  alone  involved,  and  (2)  in 
which  the  pleural  cavity  is  also  opened. 

In  a  purely  cardiac  injury  the  most  striking  features,  in  addition  to 
a  certain  reflex  pallor,  are  the  cyanosis  and  dyspnoea  of  the  patient. 
The  pulse  is  weak,  rapid,  and  markedly  irregular ;  the  heart  sounds 
are  feeble  and  appear  to  come  from  afar.  The  cardiac  dulness  is 
more  or  less  increased,  but  the  results  of  percussion  and  auscultation 
of  the  lungs  are  normal. 

We  have  just  said  that  the  cardiac  dulness  is  increased.  This  is 
true  of  most  cases  of  purely  cardiac  injury,  but  the  extent  of  the 
increase  varies  considerably.  It  must  not  be  estimated  by  the 
standard  which  obtains  in  cases  of  pericardial  effusion,  as  the 
inexperienced  are  apt  to  do.  An  acute  haemorrhage  does  not  distend 
a  healthy  pericardium  to  the  same  degree  as  a  gradually  developing 
effusion.  We  can,  therefore,  only  expect  any  considerable  increase 
in  the  area  of  dulness  after  cardiac  injuries  in  cases  wherein  blood  is 


INJURIES   OF   THE    HEART  193 

slowly  oozing  for  days.  In  the  very  severe  cases,  on  the  other  hand, 
death  is  too  sudden  to  permit  of  the  recognition  of  any  striking 
distension  of  the  pericardium. 

Observation  of  the  patient  over  a  number  of  hours  will  probably 
show  moments  of  improvement  alternate  with  periods  of  exacerbation 
which  appear  to  come  on  in  attacks,  signifying  that  the  heart  tem- 
porarily recovers,  only  to  succumb  in  the  struggle  against  unfavour- 
able mechanical  conditions.  The  exacerbations  get  worse  and  worse 
and  the  patient  sinks  unless  hjemorrhage  ceases  spontaneously  or  is 
checked  by  suture  of  the  heart. 

This  picture  constitutes  the  condition  known  as  couipression  of  the 
heart  by  means  of  the  blood  enclosed  within  the  pericardium. 
Whether  the  usual  explanation  of  auricular  compression  is  correct 
or  not  is  an  open  question. 

The  following  case  will  illustrate  the  foregoing  remarks.  A  young 
melancholic  stabbed  himself  three  times  in  the  cardiac  region  with  a 
sharp  file,  and  was  brought  into  hospital  three  hours  later  with  a 
miserable  rapid  pulse.  During  the  examination  dyspnoea  and  cyanosis 
became  severe,  the  pulse  inappreciable  and  the  eyes  glassy.  A  rib 
was  immediately  resected  and  the  pericardium,  which  was  fuU  of 
bl-ood,  was  opened.  At  this  moment  the  nurse  who  was  looking  after 
the  blood  exclaimed,  "  The  pulse  has  come  back  again  !  "  No  haemor- 
rhage had  occurred  into  the  pleura.  The  signs  were  therefore  not 
those  of  anaemia  but  of  compression  of  the  heart.  The  patient  was 
taken  back  to  bed  with  a  good  appearance  and  full  pulse.  The  heart 
was  not  sutured  because  the  hasmorrhage  ceased  spontaneously,  and 
the  patient  recovered. 

The  picture  is  quite  different  when  the  cardiac  injury  is  com- 
plicated by  injury  to  the  pleura.  If  the  pleuro-pericardial  wound 
is  large  enough  the  patient  smiply  bleeds  into  the  thoracic  cavity  and 
he  presents  the  appearance  of  an  acute  anaemia.  The  patient  looks 
pale  rather  than  cyanotic,  the  cardiac  dulness  is  very  little  enlarged, 
if  at  all,  but  an  increasing  liquid  effusion  takes  place  in  the  injured 
pleural  cavity.  The  pulse  is  rapid,  small  and  irregular,  and  the 
patient  manifests  the  same  momentary  improvements  and  sudden 
exacerbations  which  occur  in  purely  cardiac  injuries.  On  ausculta- 
tion the  cardiac  sounds  prove  to  be  feeble.  Various  valvular  mur- 
murs are  audible,  but  nothing  distinctive.  A  splashing  murmur  like 
the  sound  of  the  wheel  of  a  water-mill  is  of  more  importance,  because 
this  is  conclusive  of  the  entry  of  air  into  the  pericardium. 

We  must,  however,  not  expect  to  find  a  typical  picture  in  any 
individual  case.  If  the  pleuro-pericardial  wound  is  small  blood  may 
escape  from  it  into  the  thoracic  cavity,  so  that  the  patient  becomes  to 
a  certain  extent  anaemic  ;  but  the  opening  may  be  eventually  closed 
by  a  clot,  so  that  symptoms  of  heart  compression  will  be  present  \n 
addition  to  those   of  anaemia.     In   these   intermediate  cases  it  is  not 


194  SURGICAL   DISEASES    OF   THE   THORAX 

SO  important  to  diagnose  all  the  details  of  the  injury  as  to  recognize 
the  fact  of  cardiac  injury  as  soon  as  possible,  and  appraise  accurately 
the  indications  for  surgical  interference. 

The  following  statement  may  be  taken  as  a  guide  in  practice  : — 

If  ail  injury  in  a  situation  icJierein  the  heart  may  be  involved  is  fol- 
lowed by  derangement  in  cardiac  action  or  by  acnte  anceniia,  zve  must 
assume  the  probability  of  an  iiijurx  to  the  heart,  whether  the  cardiac  dulness 
be  increased  or  not.  If  the  symptoms  gradually  increase  despite  transi- 
tory improvement,  surgical  measures  must  be  adopted  unless  contra- 
indicated  by  external  conditions. 

"  Unless  contra-indicated  bv  external  conditions."  The  main- 
tenance of  strict  asepsis  is  so  important  in  these  operations  which 
usually  concern  the  pleura  and  pericardium  that  cardiac  suture  ought 
only  to  be  undertaken  when  all  external  conditions  are  favourable, 
unlike  the  rule  for  tracheotomy.  If  at  all  possible  the  patient  should 
be  conveyed  to  the  nearest  hospital.  Experience  shows  that  there  is 
ample  time  for  this  if  the  diagnosis  has  been  made  without  delay. 

Do  the  foregoing  remarks  justify  us  in  concluding  that  there  is  ;/o 
cardiac  injury  in  the  absence  of  anaemia  and  circulatory  distur- 
bances ?  Certainly  not.  Even  penetrating  wounds  may  run  their 
course  without  symptoms  and  may  remain  unrecognized  despite 
careful  examination. 

An  old  man  stabbed  himself  three  times  with  a  kitchen  knife  in 
the  cardiac  area.  Although  the  heart  was  most  carefully  examined 
no  sign  of  injur}'  could  be  detected.  The  patient  died  in  eight  days 
from  pneumonia,  and  the  autopsy  revealed  a  small  stab  wound  which 
had  gone  right  through  the  left  ventricle,  at  the  apex,  but  which  had 
been  sealed  up  by  fibrin.  The  pericardium  only  contained  a  little 
blood-stained  fluid. 

Such  a  case  is  not  one  for  immediate  operation,  but  it  requires 
careful  watching,  lest  subsequent  haemorrhage  necessitate  an  opera- 
tion eventually. 

A  word  of  warning  in  conclusion.  Too  much  zeal  must  not  be 
evinced  in  this  newly-acquired  surgical  province.  Many  uninjured 
hearts  have  been  exposed,  showing  the  necessity  for  most  careful 
examination  to  avoid  confusing  an  injury  of  some  other  thoracic 
organ  with  a  cardiac  injury. 


THE    SURGERY    OF    IXFLA:\niATORY    DISEASES    OF    THE    LUXG        195 


CHAPTER  XXIX. 

THE  SURGERY    OF  INFLAMMATORY  DISEASES  OF 

THE  LUNG. 

There  are  certain  diseases  of  the  lung  in  whicli  the  patient  is 
entitled  to  the  benefit  of  surgical  treatment.  Nothing  demonstrates 
this  so  clearly  as  the  action  of  a  physician  who,  doubting  the  efficacy 
of  his  prescriptions,  recently  betook  himself  to  the  knife  and  has  now- 
become  one  of  the  most  experienced  of  lung  surgeons. 

The  diagnosis  of  surgical  diseases  of  the  lung  comes  within  the 
province  of  the  physician  and  general  practitioner,  because  these 
maladies  are  purely  "  medical  "  at  first.  The  surgical  sense  of  the 
practitioner  should  evince  itself  by  recognizing  the  exact  moment 
when  resort  to  the  knife  is  required. 

Empyema,  abscess  of  lung  and  gangrene  of  the  lung  are  the 
diseases  which  are  of  main  interest  in  this  connection.  Bronchi- 
ectasis and  actino-mycosis  of  the  lung  only  rarely  lead  to  operative 
procedures.  The  surgical  treatment  of  phthisis  and  of  emphysema 
is  in  much  too  early  a  stage  to  justify  any  discussion  here. 

.4.— EMPYEMA,  ABSCESS    OF    THE    LUXG,  GANGRENE    OF 

THE  LUNG. 

From  an  etiological  standpoint  the  following  possibilities  exist  : — 
(I)  A  pneumonia  fails  to  resolve  in  the  desired  manner,  or  if 
pyrexia  recurs  after  the  crisis  the  first  thought  which  enters  one's 
mind  is  that  of  empvema.  The  diagnosis  is  made  from  dulness  at 
the  base,  weakened  respiration  and  loss  of  vocal  fremitus  and  con- 
firmed bv  exploratory  puncture.  An  empyema  extending  to  the  spine 
of  the  scapula,  and  unrecognized,  must  be  ascribed  to  a  thoughtless- 
ness on  the  part  of  the  medical  attendant.  A  careful  observer  will 
never  be  taken  by  surprise  by  an  empyema  bursting  through  into 
bronchi  or  thoracic  wall.  If  an  empyema  is  indicated  by  lever, 
dyspnoea  and  emaciation,  but  physical  signs  are  absent,  we  need  not 
doubt  the  accuracy  of  the  diagnosis,  but  must  search  for  the  empyema 
in  the  correct  situation.  It  may  be  interlobular  and  therefore  fail  to 
yield  the  ordinary  signs.  A  circumscribed  area  of  diminished  respira- 
tion and  of  dulness,  generally  with  some  adjacent  bronchial  breathing 
bounded  about  and  below  by  normal  lung  resonance  and  well- 
preserved  respiratory  murmur,  usually  directs  us  to  its  position.  A 
needle  correctly  aimed  will  demonstrate  pus  at  once.  (See  under 
Sub-phrenic  Abscess.) 


196 


SURGICAL    DISEASES    OF    THE    THORAX 


But  in  such  a  case  the  differentiation  from  abscess  of  the  kmg  is 
difficult.  This  is  also  a  frequent  sequel  of  pneumonia,  and  if  not 
situated  at  the  base  has  an  area  of  more  or  less  normal  lung  tissue 
below  it.  The  greater  extent  of  the  dulness  and  the  later  occurrence 
or  entire  absence  of  perforation  into  the  bronchi  are,  however, 
distinctive  of  empyema. 

A   skiagram    may  render   some   assistance   in   this    differentiation, 

because  a  more  or  less 
transverse  non- transpa- 
rent area  indicates  an 
empyema,  whereas  a  re- 
stricted roundish  tliicken- 
ing  points  to  abscess 
(fig-  109). 

If  the  expectoration 
has  a  peculiar  foetid  smell 
and  contains  shreds  of 
lung  tissue,  the  case  is 
no  longer  merely  one  of 
abscess  ;  it  has  become 
gangrenous. 

If  copious  pncuinonia 
has  been  the  antecedent 
disease,  as  we  have  hither- 
%  to  assumed,  experience 
shows  that  some  form  of 
empyema  is  most  pro- 
%        bablv  in   question. 

(2)   If   the  pneumonia 

has  been    caused    by  the 

inhalation  of  anv  kind  of 

foreign  body,  or  of  fluids, 

the  conditions  are  differ- 

FlG.  109.  — Skiagram  of  aljscess  of  lung  (X).  ^^^t.       It  is   quite   true   that 

empyema  is  not  a  rare 
sequel,  but  nbsccss  of  ilie  In/ig  is  of  more  frequent  occurrence,  and 
gangrene  often  follows  it. 

As  we  have  previously  seen,  foreign  bodies  include  everything 
taken  into  the  mouth  foolishly  by  children  and  adults  and  inhaled 
through  carelessness.  The  consequent  abscess  may  run  a  very  chronic 
course  and  persist  for  years,  even  ten  or  more.  I  have  seen  a  female 
aged  40  suffering  from  a  chronic  pulmonary  abscess  and  bronchiectasis 
which  she  rightly  attributed  to  inhaling  a  bean  in  her  youth. 

It  is  also  necessary  to  note  the  occurrence  of  the  inhalation  of 
fluids,  especially  in  the  vomiting  of  anaesthesia  and  in  operations  on 
the   mouth   and    throat,  for  the  removal   of  putrefying  carcinomata,. 


THE    SURGERY    OF    IXFLA:\niATORY    DISEASES    OF   THE    LUNG        I97 

or  for  the  extraction  of  teeth  undei"  general  anaesthetics.  The  extrac- 
tion of  numerous  teeth  under  anaesthesia  is  no  trifling  matter  ;  never- 
theless the  operation  is,  unfortunately,  often  undertaken  when  the 
patient  is  quite  unfitted  for  it. 

If  some  lung  complication  supervenes  with  these  circumstances 
the  diagnosis  is  generallv  easy.  i\t  first  a  pneumonia  is  diagnosed- 
If  an  effusion  takes  place  in  the  pleural  cavity  puncture  with  a  needle 
will  show  whether  it  is  serous  or  purulent.  If  the  sputum  after 
settling  separates  out  into  three  layers — the  lowest  of  pure  pus,  then 
clear  liquid  and  the  highest  of  mucus — an  abscess  must  be  present. 
If  we  are  met  by  a  repulsive  odour  on  entering  the  sick  room,  the  case 
is  either  foetid  bronchitis  or  gangrene.  The  sputum  in  the  latter  case 
is  greenish  or  brownish  and  putrid,  separating  into  three  layers,  and 
contains  greyish  or  dark  shreds  of  necrotic  lung  tissue,  or,  at  any  rate, 
elastic  fibres  visible  under  the  microscope.  If  repeated  examinations 
fail  to  reveal  any  of  these  structures,  we  must  content  ourselves  with 
the  diagnosis  of  foetid  bronchitis. 

(3)  In  a  third  group  of  cases  the  lung  symptoms  are  preceded 
neither  by  the  inhalation  of  a  foreign  body  nor  by  pneumonia.  The 
disease  follows  some  inflammatory  process  which  may  possibly  be 
situated  at  some  distance  from  the  lung;  and  the  exciting  cause  of  the 
infection  reaches  the  lung  by  way  of  an  embolism.  Any  inflamma- 
tory process  may  serve  as  the  cause,  e.g. — sore  throat,  a  furuncle, 
suppuration  within  the  abdominal  cavity,  especially  on  the  region  of 
the  female  genitalia.  If  a  few  organisms  only,  or  very  minute  par- 
ticles of  infected  material  are  conveyed,  the  result  will  be  according 
to  their  localization  either  a  pleuris}"  or  multiple  small  abscess  forma- 
tion with  the  signs  of  pneumonia.  If,  on  the  other  hand,  a  larger 
infective  thrombus  reaches  the  pulmonary  artery  a  more  or  less 
extensive  focus  of  gangrene  will  result. 

The  history  and  physical  examination,  as  we  have  seen,  usually 
suffice  for  a  correct  diagnosis.  If  an  empyema  is  confirmed  by  punc- 
ture the  indications  are  for  an  immediate  evacuation  by  surgical 
measures  either  by  simple  syphon  drainage  or  by  the  more  reliable 
method  of  rib  resection.  If  we  suspect  an  abscess  of  the  lung  or  a 
gangrenous  area,  we  must  be  more  careful  in  regard  to  puncturing, 
because  the  pleural  cavity  is  probably  still  free.  We  must  therefore 
rather  resort  to  a  skiagram  or  a  screen  examination,  and  only  proceed 
to  puncture  when  everything  is  readv  for  an  operation.  It  is  even 
better  to  abandon  the  punctui-e  altogether,  or,  at  any  rate,  until  the 
lung  is  exposed,  The  nature  of  the  expectoration  also  testifies  to 
suppuration,  and  its  position  is  more  correctly  estimated  by  means 
of  physical  examination  and  a  skiagram  than  by  puncture. 

We   have  hitherto  assumed  that  the    diagnosis   of   disease  within 


19^  SURGICAL    DISEASES    OF   THE    THORAX 

the  pleural  cavity  can  be  made  with  absolute  certainty  ;  but  this  is 
not  always  the  case.  In  discussing  subphrenic  abscess  we  shall  see 
that  it  is  very  easy  to  mistake  this  for  an  empyema,  especially  on  the 
right  side.  The  diaphragm  may  be  so  tightly  pressed  against  the 
thoracic  wall,  and  the  lung  pushed  up  so  far  that  although  the  needle 
shows  the  pus  to  be  situated  apparently  in  the  sixth  or  seventh  inter- 
costal space,  the  abscess  is  really  below  the  diaphragm.  On  the 
other  hand,  a  circumscribed  diaphragmatic  pleurisy  in  the  depths  of 
the  inferior  surface  of  the  lung  may  be  mistaken  for  a  subphrenic 
abscess. 

/?.— BRONCHIECTASIS. 

Bronchiectasis  is  either  of  congenital  origin  or  the  result  of 
some  circumscribed  inflammatory  process  of  the  lung  or  pleura,  such 
as  pneumonia  or  abscess. 

The  diagnosis  is  based  upon  the  paroxysmal  attacks  of  expectora- 
tion, amounting  sometimes  to  a  whole  mouthful,  especially  in  the  morn- 
ing ;  to  the  separation  of  the  sputum  into  three  layers — after  standing, 
and  to  the  presence  of  the  particles  of  pus  known  as  Dittrich's  plugs. 
On  physical  examination  moist  rales  are  heard  in  cases  of  small 
bronchiectasis,  and  when  large  circumscribed  cavities  are  present  the 
signs  are  those  of  infiltration  and  cavitation.  A  skiagram  should 
always  be  taken,  because  we  mav  derive  therefrom  important  con- 
clusions regarding  the  situation  and  extent  of  cavities,  if  not  about 
the  very  nature  of  the  disease  (fig.  115). 

In  the  diffuse  form  there  is  only  evidence  of  thickening  of  the 
lung  tissue,  which  is  indistinguishable  from  a  severe  tubercular  infil- 
tration ;  but  in  sacular  bronchiectasis  a  cavity  which  is  hardly 
distinguishable  from  a  tubercular  cavity  may  be  visible. 

It  is  well  known  that  clubbed  fingers  develop  after  some  years 
in  cases  of  bronchiectasis,  but  this  condition  may  also  be  due  to 
quite  different  causes,  and  is,  therefore,  not  of  much  value  from  a 
diagnostic  standpoint. 

In  the  differential  diagnosis  of  bronchiectasis  care  must  be  taken 
to  distinguish  it  from  piilmonarx  abscess  and  from  tubercular  cavities. 
If  there  are  no  tubercle  bacilli  in  the  sputum  the  latter  may  probably 
be  excluded.  Pulmonary  abscess  differs  from  bronchiectasis  in  that 
it  supervenes  directly  after  the  primary  disease,  e.g.,  pneumonia  or 
inflammation  caused  by  a  foreign  body,  whereas  bronchiectasis  takes 
months  or  years  to  develop.  If  there  has  been  no  causative  disease, 
bronchiectasis  is  the  most  probable  diagnosis. 

C— ACTINOMYCOSIS. 

The  early  stages  of  actinomycosis  of  the  lung  are  either  entirely 
overlooked  or  confused  with  tubercle.     If  the  patient  has  a  chronic 


TUMOURS   AND   ALLIED    GROWTHS   WITHIN   THE   THORAX  199 

cough  with  purulent  sputum  :uid  elevations  of  temperature,  he  will 
generally  be  diagnosed  as  a  case  of  phthisis — and  justly  so.  But 
there  are  certain  signs  which  ought  to  suggest  the  possibility  of 
actinomycosis  even  at  this  stage.  These  consist  of  a  localization 
of  the  disease  to  the  middle  and  lower  lobes,  leaving  the  apices 
free,  and  also  the  incidence  of  pleuritic  attacks  with  simultaneous 
drawing-in  of  the  chest.  A  positive  diagnosis  may  be  obtained  by 
examining  the  expectoration,  at  any  rate  if  it  contains  the  actinomy- 
cosis granules.  The  diagnosis  is  easier  when  the  disease  reaches  the 
thoracic  wall  and  becomes  evident  on  the  surface.  We  shall  return 
to  this  in  a  subsequent  section,  but  would  only  add  here  that  operative 
treatment  of  this  disease  has  affected  a  complete  cure  in  many  cases. 


CHAPTER    XXX. 


TUMOURS    AND    ALLIED    GROWTHS   WITHIN   THE 

THORAX. 

Pathological  growths  within  the  thorax  naturally  fall  under  two 
groups  :  (i)  Those  of  the  mediastinum  ;  (2)  those  of  the  lungs. 
Each  group  possesses  its  characteristic  symptom-complex,  and  will 
therefore  be  discussed  separately. 

There  are  transitional  forms  here,  as  elsewhere,  which  introduce 
difficulties  in  diagnosis.  Thus  a  small  cancer  of  the  lung  with 
enlarged  mediastinal  gland  will  yield  the  symptoms  of  a  mediastinal 
tumour,  whereas  a  sacculated  aneurism  growing  towards  one  lung 
will  suggest  the  possibility  of  a  pulmonary  tumour. 

(1)  MEDIASTINAL   TUMOURS. 

No  region  is  so  inaccessible  to  direct  examination  as  the  medi- 
astinum, and  nowhere  do  tumours  sail  so  long  under  false  colours 
as  here.  The  diagnosis  is  only  made  under  a  feeling  of  great 
responsibility,  because  the  impotence  of  therapeutics  renders  the 
diagnosis  a  sentence  of  death. 

Most  of  the  new  growths  of  the  mediastinum  chiefly  involve  the 
lung  or  the  larger  bronchi.  An  irritiiting  congli,  without  expectoration, 
and  dxspncea  are,  therefore,  the  symptoms  which  dominate  the  clinical 
picture  for  a  considerable  time  and  suggest  some  form  of  pulmonary 
disease — phthisis  in  young  people,  chronic  bronchitis  and  emphysema 


200 


SURGICAL    DISEASES    OF   THE    THORAX 


in  elderly  patients.  If  there  is,  in  addition,  paralysis  of  the  reciirreiif 
laryngeal  nerve,  the  condition  is  looked  upon  with  more  gravity, 
although  this  form  of  paralysis  may  exist  without  any  serious 
significance.  If  careful  attention  is  bestowed  on  the  form  of  the 
dyspnoea,  it  will  often  be  noted  that  an  attack  comes  on  in  certain 
postures  of  the  body  and  that  it  ceases  in  other  postures.  The  con- 
sideration of  this  symptom  should  suggest  the  possibility  of  some 
mediastinal    growth,    provided   there    is    nothing  in   the  neck   like  a 

goitre  or  other  tu- 
mour to  account 
for  it.  If  the  veins 
of  the  neck  gradu- 
ally dilate,  and  a 
collateral  venous 
anastomosis  de- 
velop at  the  same 
time,  our  suspicion 
will  secure  new  sup- 
port. At  this  stage 
there  will  generally 
be  somewhere  in 
the  thorax,  especi- 
ally over  the  ster- 
num, an  abnormal 
didness  on  'percus- 
sion, and  the  aid  of 
the  X-rays  should 
also  prove  of  ser- 
vice. As  the  tissue 
of  the  tumour  is 
less  transparent 
than  lung  tissue,  a 
mediastinal  grow'th 
of  any  appreciable 
size,  of  whatever 
nature  it  be,  will 
throw  a  superimposed  shadow  on  one  side  or  other  of  the  sternum. 
The  peculiarities  of  this  shadow  often  afford  further  diagnostic  assist- 
ance and  provide  definite  conclusions  as  to  the  nature  of  the  growth. 
But  other  clinical  methods  will  furnish  information  on  this  head. 

Let  us  consider  the  main  possibilities  :  In  infancy  the  most 
likely  condition  is  hypertrophy  of  the  thymus  gland,  or  some  unusually 
great  hyperplasia  of  the  bronchial  glands.  In  older  patients  we 
endeavour  to  decide  between  an  aortic  aneurism  or  a  genuine  tumour. 


Fig.  1 10. — Diffuse  colloid  goitre  with  a  considerable  part 
iniiide  the  thorax  (see  fig.  in).  Pronounced  caput  medusae. 
Dyspnoea. 


TUMOURS    AND    ALLIED    GROWTHS    WITHIN    THE   THORAX  201 

Innocent  tumoars  mainly  consist  of  intia-thoracic  goitres,  dermoid 
and  hydatid  cysts,  and  malignant  tumours  comprise  carcinoma  and 
sarcoma,  which  may  arise  from  the  thymus,  bronchi,  lymphatic 
glands  or  connective  tissue.  Cancer  of  the  oesophagus,  which  should 
properly  be  included  here,  is  generally  fatal  before  reaching  dimen- 
sions which  bring  it  in  the  category  of  mediastinal  tumours. 

The  early  recognition  of  hypertrophy  of  the  thymus  is  particularly 
important,  because  many  cases  have  been  successfully  operated  on. 

Hvpeiirophy  of  flie  broiicJiinl  glands  in  scrofulous,  or  rather 
in  tubercular  children,  is  only  important  surgically  as  a  matter  of 
dififerential  diagnosis.  Without  a  skiagram  the  diagnosis  is  usually 
nothing  more  than  a  suspicion,  unless  opportunely  there  are  such 
definite  signs  as  glands  in  the  neck,  dulness  over  the  sternum,  and 
paralysis  of  the  recurrent  laryngeal  nerve.  The  skiagram,  however, 
shows  these  glands  with  the  clearest  distinction,  and  should,  thei'efore, 
always  be  procured  whenever  this  diagnosis  is  entertained. 

In  adults  the  differential  diagnosis  mainly  lies  between  tumour 
and  aneurism  ;  but  the  shape  of  the  area  of  dulness  permits  of  a 
definite  conclusion  being  arrived  at.  In  large  aneurisms  the  dulness 
projects  in  front  to  one  or  both  sides  of  the  upper  part  of  the  sternum, 
and  it  appears  posteriorly  chiefly  in  the  region  of  the  left  and  some- 
times of  the  right  upper  lobe  of  the  lung.  Mediastinal  tumours  may 
present  the  same  condition  in  regard  to  dulness,  but  they  do  not 
adhere  to  any  rule. 

If  the  thoracic  wall  bulges  and  pulsates,  and  the  hand  feels  a 
definite  thrill,  and  if  a  souffle  is  heard  with  the  stethoscope,  the 
diagnosis  requires  no  great  skill,  especially  if  the  radial  pulses  are 
unequal  and  there  is  a  history  of  syphilis  (fig.  114).  But  sometimes 
nothing  is  heard  on  auscultation,  the  radial  pulse  is  equal  on  both 
sides,  and  there  is  no  previous  history  of  syphilis.  The  actual 
symptoms,  dulness,  dyspnoea,  paralysis  of  the  recurrent  laryngeal, 
intercostal  pain,  and  possibly  also  inequality  of  the  pupils  due  to 
pressure  on  the  oculo-pupillary  fibres  of  the  sympathetic  (to  be 
examined  in  semi-darkness),  the  emaciation  and  even  the  shape 
of  the  demonstrable  dulness  might  just  as  well  be  due  to  a 
mediastinal  tumour,  or,  in  exceptional  cases,  to  greatly  enlarged 
tubercular  bronchial  glands.  We  must,  therefore,  be  guided  by 
indirect  diagnostic  considerations.  The  symptoms  of  an  aneurism 
usually  come  on  very  slowly,  taking  years  to  develop,  and  the  patient 
is  quite  unconscious  of  them.  Unless  a  sudden  rupture  occurs  their 
progress  is  very  gradual.  A  mediastinal  tumour,  on  the  other  hand, 
develops  more  rapidly,  and  after  having  once  given  rise  to  symptoms 
proceeds  uninterruptedly  to  the  end. 

Sometimes  we  are  led  upon  the  right  track  by  the  condition  of 
other  organs.     Thus  we  may  conclude  from  the  presence  of  enlarged 


202 


SURGICAL   DISEASES    OF   THE   THORAX 


glands  in  the  neck,  axillae"  or  groins,  that  the  mediastinal  disease 
also  depends  upon  enlarged  glands.  The  consistence  of  these  glands 
may  perhaps  indicate  whether  they  are  leukccmic,  but  more  reliance 
is  to  be  placed  upon  the  appearance  of  the  patient  and  the  blood 
count.  But  if  the  neck  alone  presents  enlargement  of  the  glands 
of  recent  date,  we  may  assume  the  presence  of  a  primary  malignant 
tumour  of  the  mediastinum  or  of  the  lung,  unless  it  be  a  rare  case 
of  Hodgkin's  disease  beginning  in  the  mediastinum.  Fruit-juice, 
blood-stained  expectoration  would  support  the  diagnosis  of  primary 
tumour   of   the    lung.     Old-standing    pulmonary   tuberculosis   would 


Fig.    III. — Tntra-thoracic  Goitre.     S — S,  the   goitre;   consisting   of  both  lower  cornua, 
as  shown  by  the  operation,      c  =  heart,  d  =  diaphragm  and  liver. 


suggest  mediastinal  glands  of  a  tubercular  nature.  If  the  patient 
has  a  malignant  growth  anywhere,  we  should  discard  all  thoughts 
of  aneurism  and  assume  the  presence  of  a  metastasis  in  the 
mediastinum.  Sometimes  the  primary  tumour  presents  no  symptoms 
at  all^  and  the  secondary  growth  in  the  mediastinum  is  alone  in 
evidence,  as  in  fig.   113. 

But,  as  stated  above,  the  most  reliable  conclusions  are  yielded 
in  doubtful  cases  by  Roiifgcn  rays,  especially  by  examination  with 
the  screen. 


TUMOURS    AXD    ALLIED    GROWTHS    WITHIX    THE    THORAX 


203 


111  the  case  of  an  aneurism  a  thick,  sharply-limited,  rounded 
shadow  is  seen.  If  the  aneurism  arises  from  the  ascending  aorta  or 
aortic  arch,  the  shadow  is  situated  above  the  heart,  fitting  over  it  like 
a  cap,  corresponding  to  the  dulness  previously  described  (fig.  114). 
If  it  is  an  aneurism  of  the  innominate  artery  the  shadow  is  situated 
to  the  right  of  and  above  the  aortic  arch,  and  is  not  distinguishable 
from  a  saccular  aneurism  arising  from  the  arch  and  growing  towards 
the  right.  A  semi-circular  shadow  on  the  left  side,  situated  much 
lower  down,  indicates  an  aneurism  of  the  descending  aorta,  if  the 
shadow  can  be  distinctlv  defined  separately  from  the  heart  shadow. 


LciL.  Right. 

Fig.  112. — A  mass  of  mediastinal  glands  encroaching   on  the  right  lung  in  a 

case  of  lymphadenoma. 

The  penetration  of  an  aneurism  through  the  thoracic  wall  can  be 
recognized  clearly.  All  this  is  visible  in  the  skiagram,  but  the  screen 
allows  us  to  see  the  pulsatile  movement  of  the  margins  of  the  shadow. 
The  absence  of  this  pulsation  is,  however,  no  proof  against  aneurism, 
because  there  are  such  things  as  non-pulsating  aneurisms  ;  but  the 
presence  of  an  extensive  pulsatile  dilatation  of  the  margins  of  the 
shadow,  especially  if  bilateral,  mav  be  regarded  as  positive  proof  of 
aneurism.  But  if  the  pulsation  is  unilateral  only,  or  if  it  is  limited 
to  one  place,  the  case  may  be  one  of  new  growth  pushing  up  the 
aortic  arch. 

14 


J04 


SURGICAL    DISEASES    OF   THE    THORAX 


The  shadows  cast  bv  mediastinal  and  pulmonary  tumours  are 
quite  different  to  the  typical  shadow  of  aneurism.  Like  the  dulness 
produced  by  these  tumours,  their  shadows  have  no  typical  situation, 
but  they  invade  irregularlv  the  median  shadows  cast  by  the  spinal 
column  and  sternum,  either  to  the  right  or  left,  encroaching  into 
the  lung  area.  Their  limits  are  less  sharp  than  in  cases  of  aneurism 
(fig.  113),  the  border  line  especially  being  less  regularlv  defined. 
Sometimes  it  is  possible  to  see  quite  clearlv  that  the  growth  is 
composed  of  separate  nodules.  We  shall  see  later  that  there  are 
exceptions  to  this  rule. 

The  following  case  illustrates  the  considerations  which  lead  up 
to  the  diagnosis  of  aneurism. 

An  alcoholic  male,  aged  42,  who  had  been  losing  flesh  for  some 
time,  suffered  from  indefinite  general  malaise,  which  was   attributed 


Left.  Righi. 

Fig.    113. — Mediastinal    tumour.       Metastasis  from  a   hypernephroma 

which  produced  no  clinical  sjmptoms. 

to  a  cu-rhosis  of  the  liver,  with  which  he  was  afflicted.  During  the 
last  few  weeks  striking  dyspnoea  and  hoarseness  developed,  and 
the  patient  came  into  the  consulting  room  emaciated  and  short  of 
breath.  He  might  have  been  taken  for  a  case  of  advanced  phthisis, 
had  he  not  stated  that  he  had  had  no  cough  up  to  quite  recently, 
and  even  now  there  was  no  expectoration  suspicious  of  tubercle. 
The  breathing  was  rapid,  but  auscultation  disposed  of  the  idea  of 
pulmonarv  disease.  Cardiac  action  was  rapid,  but  the  heart  sounds 
were  pure,  there  were  no  bruits  or  murmurs.  The  dyspnoea  could 
not  be  accounted  for  bv  pulmonary  disease  or  by  valvular  defect. 
The  clinical  picture  did  not  fit  in  with  disease  of  the  heart  muscle. 
The  only  explanation  was  offered  bv  a  slight  dulness  on  both  sides 
of   the   upper   half   of  the   sternum,    which  might  be  caused  by  an 


TUMOURS   AXD    ALLIED    GROWTHS    AVITHIX    THE    THORAX 


20: 


aneurism  or  by  a  tumour.  The  radial  pulse  was  equal  on  both  sides. 
Rontgen-ray  examination  revealed  a  shadow,  corresponding  in  form 
to  an  aneurismal  shadow,  above  the  heart,  reaching  to  the  throat. 
There  was,  however,  no  distinct  pulsation,  and  it  was  proposed 
that  the  patient  should  come  into  the  hospital  for  further  examination 
■of  this  point  and  for  closer  observation.  But,  instead  of  coming 
to  the  hospital,  his  doctor  reported,  in  a  few  davs'  time,  that  the 
patient  had  died  from  haemorrhage  within  a  few  minutes. 

If  an  aneurism  manifests  itself  for  a  considerable  time,  merelv 
by  a  single  symptom  which  is  not  very  typical,  much  difiicultv  may 
be  encountered  before 
a  diagnosis  is  estab- 
hshed.  Thus,  I  saw  a 
patient  who  had  been 
treated  for  two  vears 
for  intercostal  neural- 
gia, the  explanation  of 
which  was  not  revealed 
by  phvsical  examina- 
tion of  the  thoracic 
organs.  Resection  of 
three  intercostal  nerves 
afforded  temporary  re- 
lief. The  recurrence  of 
the  pain  suggested  an 
X-rav  examination,  and 
then  an  aneurism  was 
discovered  ! 

Such  cases  show 
how  easy  it  is  to  ovei"- 
look  an  aneurism.     We 

do   not,    however,    mean  yiQ_  U^, — Aneurism  of  the  aortic  arch.       a  =  heart, 

to      suggest     to     certain  d  =  aneurism,  c  =  diaphragm  and  liver. 

journalists     that      they 

should  diagnose  "  ruptured    aneurism  "     anv   more   frequently   than 

they  do  at  present  in  cases  of  sudden  death. 

If,  after  considering  all  the  diagnostic  signs  of  aneurism,  we 
exclude  this  condition  and  diagnose  a  new  growth,  our  next  step 
is  to  determine  its  nature. 

We  have  already  mentioned  intra-thoracic  goitre,  dermoid  and 
hvdatid  cysts  as  innocent  tumours.  A  goitre  is  easily  recognized 
if  it  is  merelv  a  continuation  of  one,  visible  and  palpable  in  the  neck 
(deep  goitre)=  The  diagnosis  is,  however,  more  difficult  if  the  whole 
goitre  is  concealed  within  the  thorax,  and  the  corresponding  lobe 
of  the  thyroid  gland  cannot  be  felt  or  is  only  rudimentary  (pure 
intra-thoracic  goitre).      In   such   cases    the    goitre    originally   develops 


2o6 


SURGICAL   DISEASES   OF   THE   THORAX 


from  an  inferior  cornu  of  the  thyroid  gland,  extendin^^  very  low 
down.  The  goitre  grows  into  the  thorax  and  becomes  so  large  that 
it  can  no  longer  slip  out,  and  as  it  grows  it  drags  the  rest  of  the 
thyroid  lobe  down  with  it.  It  may  also  originate,  as  a  true  or  false 
secondary  goitre,  from  an  accessory  thyroid  gland. 

A  female,  aged  68,  who  had  been  suffering  from  bronchitis  for 
many  years,  came  to  the  hospital  because  of  extreme  dyspnoea. 
She  could  only  breathe  in  a  sitting  and  bent-up  position.  There 
was  dulness  on  both  sides  of  the  sternum,  and  the  skiagram  showed 
a  sharply  defined  shadow,  like  a  cap,  above   the    heart,  reaching  as 


Left.  Right. 

Fig.  115. — a  —  Cancer  of  the  right  lower  lobe  penetrating  through  the  thoracic  wall,   b  =  Diffuse 

bronchiectasis  of  the  right  upper  lobe,     c  —  Old  tubercle  of  the  left  upper  lobe. 


far  as  the  throat,  which  suggested  an  aneurism  by  its  shape.  But  its 
edge  did  not  pulsate,  and  other  evidences  of  aneurism  were  also 
wanting.  The  right  lobe  of  the  thyroid  gland  contained  a  few  small 
colloid  nodules.  Nothing  could  befelt  of  the  left  lobe  of  the  thyroid 
except  some  mdefinite  resistance  in  the  throat.  The  case,  therefore, 
appeared  to  be  one  of  intra-thoracic  goitre,  which  would  also  account 
for  the  bronchitis.  The  operation  confirmed  this  diagnosis,  and  the: 
removal  of  the  goitre  permanently  cured  the  malady.     The  operatioa 


TUMOURS   AND   ALLIED   GROWTHS   WITHIN   THE   THORAX 


207 


in  the  cases  depicted  in  figs,  no  and  112  was  followed  by  the  same 
iesult. 

Dermoids  of  the  mediastinum  are  mostly  situated  behind  the 
manubrium,  and  are  accessible  to  operative  treatment.  The  diagnosis 
has  occasionally  been  based  on  the  expectoration  of  hairs,  after 
perforation  of  the  dermoid  into  a  bronchus.  Otherwise  we  cannot 
get  much  beyond  suspicion. 

Hydatid  cysts  will  only  be  thought  of  in  districts  where  they 
are  endemic,  and  then  the  diagnosis  is  something  of  a  guess,  unless 
tlie  nature  of  the  disease  is  betrayed  by  attacks  of  urticaria. 


Fig.  116. — Metastatic  cancer  of  lung,     x  x  =  foci  in  both  lungs. 

Malignant  iinuoiin  are  recognized  by  their  rapid  growth  and  the 
correspondingly  swift  increase  of  all  symptoms.  They  are  also 
indicated  by  the  significant  extent  and  rapid  increase  of  the  dulness. 
We  have  already  referred  to  their  skiagraphic  appearances.  They 
are  usually  sarcomata,  originating  either  in  lymphatic  glands  or  con- 
nective tissue. 

(2)  TUMOURS    OF   THE    LUNG. 

Tumours  of  the  lung,  like  those  of  the  mediastinum,  consist  of 
dermoids,  hydatids,  carcinomata,  sarcomata,  and  of  chondromata, 

the  last  starting  in  the  bronchial  cartilage.     In  their  early  stages  all 


2o8  SURGICAL    DISEASES    OF   THE   THORAX 

these  growths,  if  they  give  rise  to  symptoms  at  ah,  are  mistaken 
for  tuberculosis.  A  dermoid  is  only  recognized  when  hairs  are 
coughed  up  ;  a  hydatid  onlv  when  it  bursts  into  a  bronchus  and 
causes  suffocation,  or  when  this  occurs  under  the  very  eyes  of  the 
unsuspecting  practitioner  as  a  resuh  of  an  exploratory  puncture. 
If  the  patient  does  not  succumb,  the  microscopic  examination  of 
the  fluid,  and  the  occurrence  of  urticaria  consequent  upon  the 
puncture,  will  establish  the  diagnosis.  The  skiagram,  with  its  sharply 
defined  spherical  shadow,  is  very  significant  of  hydatid  cyst.  If  the 
symptoms  do  not  accurately  lit  in  with  those  of  tuberculosis,  we 
should  think  of  a  malignant  growth,  especiahy  if  the  patient  is 
expectorating  reddish  fruit-juice  sputum.  Sometimes  cancer  can  be 
recognized  bv  particles  of  tissue  in  the  expectoration.  Malignant 
disease  of  the  lung  is  more  likely  to  be  carcinoma  than  sarcoma,. 
but  even  carcinoma  is  quite  rare. 

According  to  Schwalbe,  the  presence  of  stridor  is  in  favour  of 
sarcoma,  and  its  absence  suggests  carcinoma.  In  sarcoma,  the 
bronchial  glands  undergo  more  enlargement  than  in   carcinoma. 

The  accompanying  illustrations  of  secondary  cancerous  nodules 
in  the  lungs  show  how  clearly  tumour  areas  can  be  marked  out  by 
means  of  X-rays. 

It  is  of  interest  to  note  the  occurrence  of  lympho-sarcoma  of 
the  lungs  in  miners,  who  inhale  arsenic-containing  dust. 


CHAPTER  XXXI. 

SWELLINGS  AND  TUMOURS  OF  THE  THORAX. 

Swellings  and  tumours  on  the  surface  of  the  chest  origmate  fron> 
one  of  the  thoracic  viscera,  usually  the  lung  or  pleura,  or  from  the 
chest  wall  Itself.  It  is  important  to  arrive  at  some  decision  on  this 
fundamental  pomt  before  making  a  physical  examination,  and  this 
can  be  done  by  obtaining  a  careful  chnical  history. 

.4.— PRIMARY  DISEASE  WITH IX  THE  THORAX. 

If  the  appearance  of  a  tumour  on  the  chest  wall  is  the  final  episode 
of  a  long  history  of  illness,  which  began  with  an  irritating  cough  with- 
out expectoration,  dyspnoea  and  hoarseness,  and  which  was  followed 
by  disorders  of  the  circulation,  we  must  think  of  a  lung  or  mediastinal 
tumour,  an  aneurism  or  of  some  inflammatory  condition. 


SWELLINGS   AND   TUMOURS    OF   THE   THORAX  209 

We  must  think  of  the  possibility  of  aneurism  because  an  explora- 
tory puncture,  thoughtlessly  undertaken,  may  place  us  in  a  very 
awkward  predicament. 

We  have  already  dealt  with  the  important  points  which  concern 
tumours  of  the  mediastinum  and  of  the  lung. 

A  swelling  appearing  in  the  thorax  after  a  disease  which  began 
wxih  iiifiainuiaiory  syinptouis — either  of  an  acute  character  like  pneu- 
monia, or  of  a  chronic  character  like  a  slow  pleurisy — is  suspicious  of 
a  pleural  empvema  which  has  made  its  way  to  the  surface,  a  so-called 
"  empyema  of  necessity."  Nowadays  we  lay  more  stress  on  the 
"  necessity "  of  operative  treatment  before  the  pus  has  become 
subcutaneous. 

We  will  give  three  typical  cases  illustrating  the  most  important 
forms :  — 

(i)  The  empyema  which  has  burst  through  may  be  of  an  acute 
infective  variety. 

A  middle-aged  man  suffered  from  a  circumscribed  pneumonia, 
with  which  signs  of  pleurisy  were  associated.  A  diffuse,  phlegmonous, 
rapidly  extending  swelling  at  the  back  indicated  the  urgency  of 
surgical  aid.  Examination  showed  that  there  was  an  effusion  into 
the  left  pleural  cavity  with  a  phlegmonous  swelling  of  the  soft  parts 
on  the  corresponding  thoracic  wall.  Diagnosis:  ruptured  empyema. 
This  was  confirmed  by  operation.  The  rupture  was  due  to  a  cause 
which  is  in  no  way  unique.  Two  days  beforehand  the  pleura  was 
punctured  for  bacteriological  diagnosis,  and  evidently  this  afforded 
an  opportunity  for  the  introduction  of  infection  from  the  soft  parts 
along  the  puncture  wound.  This  is  a  lesson  that  in  acute  cases  opera- 
tion  should   immediately  follow  puncture,  should  pus  be  discovered. 

(2)  Another  variety  is  of  tubercular  origin. 

A  young  man,  whose  previous  history  pointed  to  tubercle,  com- 
plained about  the  gradual  development  of  a  painless  swelling,  about 
the  size  of  a  goose's  egg,  immediatelv  to  the  right  of  the  sternum. 
The  swelling  could  not  be  displaced,  and  it  did  not  undergo  any 
change  in  volume  with  respiration,  indicating  some  connection  with 
the  interior  of  the  chest.  But  there  were  definite  evidences  of  tuber- 
cular disease  over  the  right  upper  lobe  of  the  lung,  which  led  to  the 
conclusion  that  there  was  some  direct  connection  between  the  two 
conditions.  Operation  showed  that  the  superficial  abscess  was  in  direct 
connection  with  an  encapsuled  collection  of  pus  within  the  thorax. 

If  the  tumour  could  have  been  displaced  our  diagnosis  would  have 
been  better  founded.  This  symptom  was  absent  because  the  intra- 
pleural collection  of  pus  was  quite  small  in  circumference,  and  was 
bounded  by  firm  and  indurated  tissue. 

If  a  cavity  ruptures  externally  the  swelling  will  evidently  contain 
gas.  There  is  always  some  secondary  infection  in  a  cavity,  and  this 
confers  acute  inflammatory  characters  upon  the  abscess,  as  happens 
when  a  purely  tubercular  collection  of  pus  breaks  through. 


210  SURGICAL   DISEASES   OF   THE    THORAX 

We  shall  subsequently  enter  into  the  details  of  differential 
diagnosis  between  a  tubercular  empyema  which  has  burst  through, 
and  tuberculosis  of  the  ribs. 

(3)  The  third  possibility  is  illustrated  by  the  following  case  : — 

A  young  girl,  suffering  from  symptoms  of  chronic  pleurisy,  was 
admitted  to  the  hospital  with  a  bilateral  effusion.  The  needle  met 
with  pus  on  the  left  side,  but  not  on  the  right.  Resection  of  the 
ribs,  on  the  left  side,  was  performed.  The  chronic  course  of  the 
disease  and  the  curious  appearance  of  the  pus  suggested  tubercle  at 
first;  but  the  pus  really  contained  filaments  similar  to  actinomvces, 
without  granules.  After  a  little  while  a  swelling  appeared  in  the 
anterior  axillary  line  parallel  with  the  ribs.  At  the  periphery  it  was 
board-like  in  consistence,  without  any  reddening  of  the  skin,  whereas 
in  the  middle  it  was  soft  and  red.  Even  without  the  bacteriological 
examination  of  the  left  side  these  appearances  would  have  strongly 
suggested  actinomycosis.  As  a  matter  of  fact,  the  pus  from  the  right 
side  contained  the  characteristic  granules  in  large  amount. 

Here,  as  in  all  cases  of  pulmonary  actinomycosis,  the  first 
thought  was  of  tubercle.  This  rare  disease  can  only  be  identified 
by  the  discovery  of  the  actinomycotic  filaments  or  the  characteristic 
granules  in  the  sputum  or  pus,  unless  the  board-like  infiltration  pre- 
viously described,  which  indicates  that  the  process  has  reached  the 
surface,  betrays  the  correct  diagnosis  to  the  experienced  eye. 

L'.— PRIMARY  DISEASE  OF  THE  THORACIC  WALL. 

If  nothing  in  the  history  or  physical  examination  points  to 
disease  of  the  thoracic  viscera,  we  must  assume  that  the  structure 
under  investigation  arises  from  the  boiiv  ivall  of  tlic  cJicst  or  from  its 
integuuieiils.  We  are  not  here  concerned,  however,  with  tumours  of 
the  mammary  glands,  as  these  are  dealt  with  in  a  separate  chapter. 

(1)  ACUTE  DISEASES. 

Acute  sivelliiigs  need  not  detain  us  long,  as  they  rarely  occur  on  the 
chest.  The  principal  one  is  acute  osteomyelitis  of  the  scapula 
or  clavicle,  which  can  hardly  be  mistaken  for  anything  else.  The 
sudden  onset  with  rigors  and  high  temperature  indicate  the  nature  of 
the  disease,  and  the  bone  affected  is  shown  by  the  position  of  the 
swelling  and  the  pain  on  pressure.  An  acute  osteomyelitis  of  a  rib, 
which  is  very  rare,  might  be  mistaken  for  an  empyema  which  has 
broken  through,  but  in  the  latter  case  the  distinctive  antecedent 
symptoms  would  not  have  been  present. 

Phlegmonous  processes  are  not  of  rare  occurrence  in  the  vicinity 
of  the  axilla.  They  generally  originate  in  lyiiipJiaiic  glands,  the  infec- 
tion being  introduced  from  the  periphery.     The  experienced  observer 


SWELLINGS    AND    TUMOURS    OF   THE    THORAX  211 

will  at  once  examine  the  fingers,  and  look  on  each  one  for  some 
lesion,  however  insignificant. 

Sometimes  red  streaks  of  lymphangitis  lead  towards  the  original 
wound.  Frequently  the  wound  is  already  healed  by  the  time  an 
abscess  has  developed  in  the  axilla. 

Occasionally  very  deep  axillary  abscesses  form,  as  a  result  of 
^iciite  pustules  and  funuides  which  are  not  infrequent  in  this  region. 
Purulent  inflammation  of  the  siveat  ghinds  (hydro-adenitis)  should 
also  be  mentioned. 

Finally,  a  phlegmon  may  develop  under  the  pectorals,  tracking 
towards  the  axilla,  and  it  may  be  cpiite  impossible,  despite  the  most 
careful  examination,  to  trace  the  entrance  of  the  infection. 


(2)  CHRONIC   DISEASES. 

In  a  gradiiaUx  developing  swelling  our  first  endeavour  is  to  decide 
whether  it  is  inflammatory  or  a  new  grow'th.  As  cystic  tumours, 
apart  from  those  of  the  breast,  occur  very  rarely  on  the  thorax,  fiuid 
contents  point  to  pus.  The  only  difficulty  is  to  be  sure  of  the  fluid, 
because  it  is  not  always  easy  to  differentiate  the  fluctuation  of  fluid 
in  small  tumours  from  the  soft  elastic  consistence  of  a  lipoma,  for 
example.  The  beginner  is  apt  to  confuse  fluctuation  with  this  soft 
elasticity,  even  in  the  case  of  larger  tumours.  When  in  doubt  as 
between  a  lipoma  and  an  abscess,  one  should  remember  that  a 
lipoma  is  characterized  by  a  lobulated  structure  and  numerous  slight 
puckerings  of  the  skin,  whereas  the  skin  over  an  abscess  is  quite 
smooth.  The  doubt  can  at  once  be  solved  by  a  puncture,  but  this 
should  be  left  to  the  end  of  the  examirjation  if  it  is  indispensable.  If 
■suppuration  has  not  yet  occurred  an  inflammatory  origin  would  be 
indicated  by  spontaneous  pain  and  tenderness  on  pressure. 

(a)  Chronic  Inflammatory  Processes. 

Tnbei-ciilosis  and  sxpJiilis  are,  with  few  exceptions,  the  principal 
causes  of  chronic  inflammatory  conditions  on  the  thorax,  whether 
the  swelling  be  non-suppurative  or  whether  it  be  an  abscess.  The 
inflammation  may  start  in  one  of  three  tissues,  viz.,  lyniphalic  glands, 
muscles,  or  bones. 

Chronic  inflammatory  processes  starting  in  the  lyinpluilic  glands 
are  of  a  tubercular  nature.  They  are  situated  in  the  neighbourhood 
of  the  axilla — ^sometimes  in  front  in  the  infra-clavicular  fossa,  some- 
times below,  between  the  anterior  and  posterior  axillary  line,  and 
sometimes  behind,  under  the  scapula.  The  infra-clavicular  glands 
cannot  as  a  rule  be  felt  separately,  like  the  cervical  glands,  because 
thev   are    situated  under   a   thick    laver  of    muscle.     When  they  are 


212 


SURGICAL   DISEASES   OF   THE   THORAX 


diseased  they  present  the  appearance  of  a  diffuse  sweUing  of  the 
deeper  tissues,  firm  at  first,  but  eventually  declaring  itself  as  an 
abscess  which  reaches  the  surface.  But  tubercular  glands  in  the 
axilla  feel  exactly  like  those  in  the  neck,  and  are  therefore  easily 
recognizable.  The  axillary  glands  are,  however,  rarely  aft'ected  alone. 
The  cervical  glands  are,  as  a  rule,  also  involved.  As  in  the  case  of 
the  neck,  there  is  also  here  the  liability  of  confusing  tubercle  with 
malignant  lymphoma ;  but  we  have  already  referred  to  the  dift'erential 
diagnosis  in  discussing  tumours  of  the  neck. 

If  an  inflammatory  area  is  situated  within  a  muscle,  the  condition 
is  usually  fnberciilai',  und  rarely  guminatoiis.      It  manifests    itself  as  a 

painful  hard  little  tumour^ 
and  its  intra  -  muscular 
situation  is  easily  recog- 
nized by  the  fact  that  it 
is  freely  movable  when 
the  muscle  is  relaxed,  and 
is  quite  fixed  when  the 
muscle  is  contracted. 

But  most  of  these 
inflammatory  processes 
arise  from  the  bones, 
and  all  the  bones  of 
the  thorax  and  shoulder 
girdle  participate  therein ; 
the  clavicle  is,  however, 
rarely  at  fault.  There  is 
one  important  distinction 
in  regard  to  disease  of 
these  various  bones,  for, 
whereas  disease  of  the 
superficial  bones,  like  the 
ribs,  sternum,  and  parts 
of  the  shoulder  blade, 
may  be  recognized  in  the  earliest  stage  before  an  abscess  develops, 
spinal  caries  is  only  diagnosed  after  an  abscess  has  formed,  unless 
attention  has  been  directed  to  the  matter  by  functional  disturbances. 
In  these  cases  the  abscess  has  often  tracked  a  considerable  way  before 
reaching  the  surface. 

A  swelling  of  the  clavicle  of  gradual  origin  should  at  once  suggest 
malignant  new  growth,  because  tubercle  and  gumma  are  of  very  rare 
occurrence  there.  If  no  other  new  growth  is  discoverable  we  must 
regard  it  as  a  primary  sarcoma.  But  microscopic  examination  will 
often  surprise  us,  and  indicate  that  a  primary  carcinoma  is  concealed 


Fig.  117. — Tubercle  of  the  sternum. 


SWELLINGS    AND    TUMOURS    OF   THE    THORAX 


21^ 


somewhere.  Cdiicer  of  the  thyroid,  breast,  or  prostate  should  suggest 
themselves,  because  their  secondary  deposits  preferably  affect  the 
bones ;  but  tumours  of  other  glandular  organs,  such  as  the  gastro- 
intestinal tract,  should  also  be  thought  of. 

If  there  gradually  form  over  a  rib  a  spindle-shaped  swelling,  rather 
painless  in  itself,  but  still  sensitive  on  pressure,  we  should  at  once 
think  of  tubercle,  but  even  here  an  error  is  possible.  Sometimes  a 
gumma  of  the  periosteum  of  the  rib  may  have  features  very  similar 
to  tubercle. 

Primary  disease  of  the  marrow  (as  shown  by  skiagram)  points  lo 
tubercle ;  primary  perios- 
titis is  not  decisive. 

A  young  man  was 
admitted  to  the  hospital 
with  a  spindle-shaped, 
somewhat  sensitive  swell- 
ing at  the  junction  of  the 
fourth  rib  and  cartilage. 
The  case  had  been  dia- 
gnosed as  tubercle,  and 
the  patient  had  been 
treated  with  iodoform 
injections.  An  aftirma- 
tive  answer  was  given  to 
the  question  whether  he 
had  suffered  from  ixplioid 
fever,  and  he  added  that 
the  swelling  started  a  few 
weeks  after  his  recovery 
therefrom. 

It  is  quite  conceiv- 
able that  typhoid  fever 
may  excite  tubercular 
disease  when  a  predis- 
position exists  towards 
it — I  have  seen  this  in  lymphoma  of  the  neck.  But  such  an  assump- 
tion was  out  of  the  question  in  this  case.  We  know  that  post-typhoid 
osteitis  and  chondritis  of  the  ribs  represent  a  special  type  of  disease, 
with  a  very  chronic  course.  Sometimes  recovery  occurs  spontane- 
ously, sometimes  only  after  the  extrusion  or  operative  removal  of  a 
bony  or  cartilaginous  sequestrum. 

On  the  stcniiiiii  the  diagnosis  lies  between  tubercle  (fig.  117)  and 
gumma,  but  we  should  also  think  of  malignant  new  growth  as 
long  as  no  suppurative  softening  of  the  tumour  has  occurred.  The 
differential  diagnosis  is,  however,  difficult,  and  Kiister  has  removed  a 
large  gumma  in  mistake  for  a  sarcoma.     In  doubtful  cases  a  Wasser- 


FiG.  118. — Thoracic  wall,  perforated  by  aneurism  of 

ascending  aorta. 


2  14 


SURGICAL   DISEASES   OF   THE    THORAX 


man  11  test  ought   to  be   undertaken,  and   a  trial    made  with    specific 
treatment  before  operating. 

The  constitution  of  the  pus  brought  away  by  the  syringe  may 
afford  some  information,  before  the  bacteriological  examination  is 
made.  Flakv,  verv  liquid  pus  points  to  tubercle,  viscous  mucoid 
pus  points  to  gumma,  but  this  rule  is  not  always  maintained. 

On  one  occasion  I  saw  a  young  man,  who  had  a  tubercular  family 
history,  with  a  swelling  over  the  manubrium  sterni.  There  was  no 
evidence  of  acquired  syphilis,  and  hereditary  infection  was  im- 
probable. The  pus  ob- 
tained bv  the  syringe  was 
brownish,  viscous,  and 
mucoid.  Xevertlieless  the 
guinea-pig  which  was  in- 
oculated became  tubercu- 
lous and  the  treatment  by 
potassium  iodide  which 
had  been  started  was  quite 
ineffectual. 

Swellings     of     gradual 
orio'in  on  the  shoiihlcj-  blade 


Fig.  119. — Pigmented  nreviis  of  the 
lumbar  region,  with  partial  sarcomatous 
degeneration. 


Fig.  120. — Fibro-sarcoma  of  the  skin  of  the  back. 


are  usually  tubercular  or  sarcomatous.  In  the  early  stages  there 
mav  be  some  serious  difficulty,  because  adjoining  the  hard  places 
are  to  be  found  soft  portions,  which  resemble  abscesses,  a  circum- 
stance which  also  occurs  with  tumours.  But  when  suppuration 
takes  place  in  tubercle  it  becomes  evident,  in  a  short  time,  and 
often  becomes  quite  extensive ;  so  that  in  every  case  where  the 
diagnosis  is  doubtful  we  must  suspect  sarcoma  and  treat  accordingly. 
Anvhow,  an  earlv  exploratory  incision  allows  radical  measures  to  be 


SWELLINGS   AND   TUMOURS   OF   THE   THORAX 


215 


undertaken  in  a  case  of  tubercle,  and  offers  the  only  prospect  of 
cure  in  sarcoma. 

A  history  of  injury  is  of  no  special  value  either  for  the  one  or  the 
other  diagnosis,  because  an  injury  may  excite  either  tubercle  or 
sarcoma.     The  following  is  an  example  of  the  former. 

A  young  lad  was  for  a  long  time  engaged  in  unloading  very  heavy 
cement  pipes,  which  he  always  carried  on  his  right  shoulder.  After 
about  two  months  a  swelling  appeared  over  the  supraspinous  fossa, 
and  a  number  of  abscesses  developed  which  clearly  contained  tuber- 


\ 


Fig.  121. — Unilateral  lipoma  of  the  back. 


Fig.   122. — Symmetrical  lipomata  of  the 
shoulders  and  loins. 


cular  pus.  It  is  difficult  in  a  case  like  this  to  avoid  considering  the 
persistent  trauma  to  be  the  opportune  cause  of  the  tubercular  attack. 
But,  of  course,  this  does  not  mean  that  the  tubercle  was  the  "  con- 
sequence of  the  injury,"  in  the  legal  sense. 

If  a  cold  abscess  on  the  back  appears  to  have  no  relation  either 
with  a  rib  or  the  shoulder  blade,  it  probably  arises  from  a  vertebra 
— from  the  transverse  process,  vertebral  arch  or  spinous  process. 

The   behaviour  of  these  abscesses  gives  rise  to  many  interesting 


2l6 


SURGICAL   DISEASES   OF   THE   THORAX 


problems  of  diagnosis,  although  they  may  have  little  connection  with 
the  origin  of  these  abscesses.  A  burrowing  abscess,  after  bursting 
through  layer  upon  layer,  from  its  deep  origin,  may  spread  widely 
over  the  surface.  The  superficial  position  of  an  abscess  is,  therefore, 
no  argument  against  its  origin  from  bone.  But  if  we  are  able  to 
demonstrate  the  deep  origin  of  an  abscess,  we  shall  be  all  the  more 
decided  in  our  search  for  the  diseased  bone  which  gave  rise   to  it. 

An  abscess  above  the  fascia  is  always 
more  prominent  because  the  contrac- 
tion of  the  underlying  muscle  gives 
it  a  firm  base.  If  the  pus  is  situated 
within  or  under  the  muscle,  the  shape 
of  the  abscess  is  obliterated  by  mus- 
cular contraction,  and  in  the  intra- 
muscular position  the  abscess  which 
is  movable  together  with  the  muscle 
is  itself  immovable  over  the  muscle. 

The  classical  signs  of  spinal  caries 
(which  see)  are  of  much  more  impor- 
tance for  its  diagnosis  than  the  variable 
behaviour  of  the  abscesses  to  which  it 
may  give  rise.  These  signs  are  mus- 
cular fixation  of  the  spine  (rigidity), 
pain  on  axial  pressure — not  always — 
curvature,  and  local  sensitiveness  to 
pressure.  The  last  S3'mptom  is  the  one 
chiefly  present  in  tubercle  of  the  pos- 
terior portion  of  the  vertebra,  which 
is  concerning  us  just  now,  the  pain  on 
pressure  being  manifest  on  the  affected 
spinal  process.  But  this  sign  is  only  of 
value  if  the  sensitive  spine  is  not  con- 
tiguous with  the  wall  of  the  abscess, 
but  lies  above  it.  In  the  absence  of 
any  sign  of  spinal  caries,  we  cannot 
decide  whether  the  disease  arises  from 
the  vertebra  or  from  the  posterior  seg- 
ment of  a  rib,  unless  a  skiagram  clears 
the  matter  up.  But  if  this  also  leaves  us  in  the  lurch  we  must  con- 
clude in  favour  of  the  more  frequent  occurrence,  i.e.,  spinal  caries. 


Fig.  123. — Fibro-lipoma  of  the 
muscles  of  the  back. 


(b)  Tumours. 

We  now  proceed  to  those  morbid  structures  which  are  recognized 
as  tumours,  without  any  qualification. 

The  innocent  tumours  on  the  skin  are  sebaceous  cysts,  angiomata 
and  fibromata,   the  last  in    the  form  of  soft  warts.      The  ordinary 


SWELLINGS   AND   TUMOURS   OF   THE   THORAX 


217 


rules  are  applicable  to  their  diagnosis  (fig.  124).  Sarcomata  of  the 
skin  usually  start  in  pigmented  or  in  non-pigmented  warts  (fig.  119). 
The  chief  signs  of  malignancy  are  sudden  rapidity  of  growth,  harden- 
ing of  consistence,  and  bleeding  on  slight  provocation.  Every 
tumour  of  the  skin  which  has  not  existed  for  a  long  time  and  which 
feels  hard  should  be  suspected  of  malignancy. 

Rarely,  slowly  growing   sarcomata  occur  on  the  skin,   and  then 
"they  may  be  more  or  less  pendulous  (fig.  120),  but  never  so  much  as 
lipomata.  Their  firm  con- 
sistence, from  the  begin- 
ning, excludes  all  doubt. 

Lipomata,  which  are 
so  frequent  on  the  back 
(fig.  121),  have  their  seat 
of  origin  in  the  subcuta- 
neous fat.  They  are  at 
once  identified  by  their 
lobulated  form  and  by 
the  slight  puckering  of 
the  overlying  skin.  There 
is  no  difficulty  in  dis- 
tinguishing them  from 
cold  abscesses. 

The  back,  just  like 
the  neck,  may  present 
symmetrical  lipomata 
(tig.  122)  as  well  as  the 
more  usual  unilateral 
variety.  They  are  gene- 
rally associated  with  a 
development  of  multiple 
lipomata  over  the  whole 
body,  and  constitute  a 
feature  of  so-called  Der- 
cum's  disease  (see  neck). 

Tubercular  abscesses 
of  the  scapula  often  imi- 
tate perfectly  the  usual 
lipomata  of  the  back, 
and  are  easily  mistaken 
for  them.  They  may  be  even  more  easily  confused  with  the  rare  cystic 
lymphangiomata  of  the  subcutaneous  tissue.  The  latter,  which  are 
always  of  congenital  origin,  although  they  may  not  appear  until  later 
in  life,  often  occur  in  the  vicinity  of  the  axilla.  They  feel  soft  like 
lipomata,  but  in  some  parts,  where  comparatively  large  cysts  are 
present,  there  may  be  genuine  fluctuation.  But  they  are  distinguished 
from  lipomata  by  the  fact  that  they  are  not  clearly  defined  from  the 
surface  on  which  they  rest,  as  they  send  processes  downwards  between 


Fig.  124. — Multiple  fibromata  of  the  skin  in  a 
woman.  One  situated  on  the  perinreum  looks  like  a 
scrotum.  Under  the  right  scapula  there  is  a  deeply- 
placed  neuro-fibroma. 


2l8  ;         SURGICAL   DISEASES   OF   THE   THORAX 

the  muscles.  Sometimes  the  overlying  skin  is  so  thin  that  the  whole 
structure  is  almost  transparent,  like  a  hydrocele  over  which  the  skin 
is  made  tense. 

If  there  is  any  doubt  about  the  relations  of  a  tumour  of  the  sub- 
cutaneous tissue  to  the  deeper  parts  it  is  only  necessary  to  make  the 
muscle  beneath  contract  in  order  to  see  whether  the  tumour  is  held 
fast  bv  this  action  or  not. 

Tumours  may  also  arise  from  the  nuisdes  or  fascia'.  They  are 
mostlv  sarcomata,  and  more  rarely  fibromata  or  lipomata.  One 
example  will  suffice. 

A  little  boy  had  on  his  back,  near  the  spine,  a  flat,  long,  oval 
tumour  (fig.  123)  with  a  lobular  outline  which  suggested  a  lipoma. 
But  it  did  not  actually  lie  in  the  skin,  which  could  be  easily  picked 
up  over  it.  On  the  other  hand,  it  was  not  connected  with  the  bone, 
because  it  was  quite  movable  over  it.  The  tumour  was  held  fast  on 
muscular  contraction,  showing  that  it  was  connected  with  the  muscles. 
The  aponeurosis  became  very  definitely  tense  over  it  when  the 
muscles  contracted.  It  was  so  well  circumscribed  that  no  suggestion 
of  an  infiltrating  malignant  growth  could  be  entertained.  Its  cake- 
like flatness  pointed  to  an  innocent  growth,  and  this  view  was  more 
consistent  with  the  anatomical  conditions,  especially  the  pressure  of 
the  fascia,  than  would  be  the  idea  of  a  sarcoma.  The  diagnosis, 
therefore,  appeared  to  be  :  sub-aponeurotic  or  intra-muscular  lipoma 
or  fibroma.  As  a  matter  of  fact,  it  was  a  lipoma  rich  in  connective 
tissue,  which  had  been  flattened  out  between  the  muscle  and 
aponeurosis. 

If  a  tumour  is  not  movable  over  the  bone,  it  has  either  arisen 
therefrom  or  become  adherent  to  it  secondarily.  We  assume  the 
former  if  this  immovability  has  been  noted  early  or  from  the  very 
beginning. 

Primarv  tumours  of  the  bone  are  either  enchondromata  or  sarco- 
mata;  and  much  more  rarely  osteomata.  Histologically,  the  former 
are  innocent,  but  their  clinical  behaviour  manifests  all  transitions  to 
pronounced  malignancy.  They  appear  as  round  protuberant  growths, 
and  are  distinguished  by  the  enormous  circumference  which  they 
may  attain.  Sarcomata  may  also  reach  to  a  considerable  circum- 
ference. It  is  important  to  know  whether  the  growths  extend  into 
the  chest,  and  how  far.  These  tumours  often  resemble  icebergs  in 
the  respect  that  the  portion  visible  is  the  smallest  part  of  their  mass. 
Auscultation  and  percussion  may  yield  definite  information  on  this 
point.  But  a  skiagram  is  more  conclusive,  and  one  ought  to  be 
taken  before  venturing  upon  any  rash  removal  of  such  a  growth. 

Finally,  if  we  find  in  the  middle  line  of  the  back  a  tumour  only 
slightly  movable  over  the  spine,  we  should  at  once  think  of  spina 
bifida  and  its  sequelae,  which  we  will  refer  to  later  on  in  detail. 


INFLAMMATORY    DISEASES    OF   THE    BREAST  219 

CHAPTER  XXXII. 

INFLAMMATORY  DISEASES  OF  THE  BREAST. 

Everyone  feels  capable  of  diagnosing  such  a  superficial  and  easily 
recognizable  disease  as  mastitis.  Nevertheless  it  is  sometimes  mistaken 
for  cancer — not  only  tubercular  mastitis,  but  even  the  ordinary  acute 
infective  condition.  The  following  considerations  should,  however, 
prevent  error  : — 

(i)  Tumours  rarely  occur  before  20,  and  they  are  not  very  frequent 
between  20  and  30.  On  the  other  hand,  inflammatory  conditions  are 
rare  after  50. 

I  have,  however,  opened  a  large  retro-mammary  abscess,  diagnosed 
as  a  new  growth,  in  a  woman  of  60.  The  breast  stood  forth  in  a 
semi-spherical  shape,  and  the  swelling  felt  hard  like  a  growth,  because 
the  abscess  was  behind  the  gland.  Even  intra-ixiammary  subacute 
abscesses  in  old  women  are  mistaken  for  carcinomata,  an  instance 
of  which  is  depicted  in  fig.  126.  The  patient  was  49  years  of  age, 
and  the  swelling  in  the  breast  was  onl}^  slightly  tender  on  pressure  ; 
but  the  oedematous  indurated  condition  of  the  skin  over  it  enabled  a 
diagnosis  to  be  made  quite  easily. 

(2)  An  association  with  the  puerperal  period  is  of  special  importance 
for  the  diagnosis,  because  this  always  points  to  inflammation,  notwith- 
standing the  slow  progress  of  the  swelling  and  the  absence  of  fever. 

A  case  was  referred  to  me,  with  an  induration  in  the  breast,  which 
came  on  gradually  several  months  after  the  patient  had  recovered  from 
puerperal  mastitis.  It  was  considered  to  be  suspicious  of  carcinoma, 
but  a  small  incision  cleared  up  the  matter,  by  the  appearance  of  a 
small  amount  of  staphylococcic  pus.  In  these  atypical  cases  of 
mastitis  sugar  is  sometimes  found  in  the  urine. 

(3)  On  the  other  hand,  it  must  be  remembered  that  a  rapidly 
growing  malignant  tumour  with  extensive  destruction  of  tissue  may 
cause  oedema  and  redness  of  the  skin  before  ulceration  or  bacterial 
invasion  occurs,  and  this  may  lead  to  errors  of  diagnosis.  But  in 
these  cases  the  history  will  usually  show  that  a  growth,  independent 
of  the  skin,  was  present  for  some  time  before  the  inflammatory 
symptoms. 

(1)  ACUTE   INFLAMMATIONS. 

We  will  now  consider  the  various  forms  of  mastitis,  beginning  with 
the  acute  forms. 

[a)  The  inflammation  of  the  breast  which  occurs  in  infancy  or  at 
puberty,  but  sometimes  also  in  the  intervening  period,  in  both  sexes, 
and  which  very  rarely  suppurates,  presents  no  difficulty  in  diagnosis 
The    gland  feels    like    a    hard    round    plate    which    is    movable   over 

15 


220 


SURGICAL   DISEASES    OE    THE    THORAX 


the  underlying  muscle.     It  is  very  painful  at  first,  and   may  remain 
tender  for  a  long  time  after  the  subsidence  of  the  acute  symptoms. 

This  persistence  of  pain  caused  me  to  shell  out  the  breast  of  a 
young  man,  at  his  urgent^request,  retaining  the  integument  of  skin  and 
the  nipple — an  operation^  which  is  not  justifiable  in   a   female.      An 


[EiG.  125. — Abscess  in  the  outer  half  of  the  left  breast.      Retraction,  but  no  elevation  of 

the  nipple. 

irritable  condition  of  breast  in  girls  at  puberty  has  been  attributed  to 
masturbation — whether  with  justice  remains  doubtful — and  this  must 
not  be  confused  with  a  bacterial  inflammation. 

(b)   Puerperal    mastitis   is  the  type   of  acute  infiainination  of  ilie 
breast,  and  in  its  classical  form  is  incapable  of  leading  to  an  error  in 


INFLAMMATORY    DiSEASfiS    OF   THE    BRf-AST  221 

diagnosis.  A  mistake  can  only  arise,  as  previously  mentioned,  when 
the  onset  of  the  inflammation  is  delayed  until  months  after  the 
confinement,  and  does  not  occur  within  the  first  few  w^eeks  as  is 
generally  the  case.  But  in  such  a  case  there  will  have  been  slight 
inflammatory  attacks  soon  after  the  confinement. 

The  condition  previously  termed  stagnation  of  milk  is  now^  known 
to  be  a  mild  infective  process  taking  place,  either  in  the  milk  congested 
within  the  ducts  and  their  ramifications,  or,  as  is  more  usual,  in  the 
connective  tissue. 

It  is  important  to  recognize  the  degree  of  the  inflammation  and  the 
site  of  the  suppuration  for  the  purpose  of  treatment.  If  the  tempera- 
ture subsides  after  the  initial  rigor  and  the  pain  ceases  after  a  few  davs, 
suppuration  is  improbable.  But  if  slight  fever  persists,  and  if  a  soft 
area,  however  small,  appears  in  the  middle  of  the  infiltrated  segment 
of  the  breast,  it  is  quite  certain  that  pus  is  present. 

As  far  as  the  position  of  the  pus  is  concerned,  we  must  distinguish 
between  abscesses  in  front  of,  ///,  and  behind  the  breast.  The  superficial, 
purely  subcutaneous  abscesses  are  usually  situated  in  the  vicinity  of 
the  areola  and  arise  from  a  circumscribed  superficial  lymphangitis. 
There  is  no  difficulty  about  their  diagnosis. 

Abscesses  within  the  parenchyma  appear  at  first  as  more  or  less 
w^ell  defined  firm  nodules,  over  which  the  skin  is  still  normal.  If 
spontaneous  resolution  does  not  occur,  the  skin  becomes  immovable, 
cedematous,  and  finally  reddened,  a  soft  area  developing  in  the 
middle  of  the  hard  portion.  If  the  abscess  is  not  opened  at  this 
juncture  it  spreads  further  under  the  skin  and  pronounced  fluctuation 
can  be  detected. 

Deep,  retro-mammary  abscesses  arise  from  deep  intra-mammary 
foci,  which  take  the  nearest  course  and  spread  towards  the  loose 
connective  tissue  behind  the  breast.  The  whole  gland  may  be  dift'usely 
tender,  but  sometimes  there  is  a  complete  absence  of  pain  and  the 
diagnosis  must  be  based  on  apparent  enlargement  of  the  breast,  due 
to  its  abnormal  prominence, 

(c)  An  acute  mastitis  may  occur  at  any  age  without  the  above 
mentioned  causes,  through  infection  of  a  nipple  which  has  been 
mechanically  irritated,  but  this  is  rare. 


(2)    CHRONIC    INFLAMMATIONS. 

These  are  generally  due  to  tubercle,  rarely  to  gumma  or  actino- 
mycosis. But  one  may  repeat  here  what  was  said  at  the  beginning  of 
the  chapter,  that  the  sub-acute  or  chronic  staphylococcic  or  strepto- 
mycotic  infections  also  occur. 

{a)  Tuberculosis  of  the  breast   may  appear  as  an  isolated  nodule 


222 


SURGICAL   DISEASES    OF   THE   THORAX 


and  thus  be  mistaken  for  carcinoma.  But  the  presence  of  other 
tubercular  stigmata,  and  enlarged  glands  in  the  axilla,  which  rapidly 
become  adherent  to  the  skin  and  soften,  would  be  strongly  suggestive 
of  tubercle.  The  diagnosis  is  easier  if  several  tubercular  foci  are 
present  in  the  breast,  and  especially  if  some  of  these  foci  have 
softened  in  places,  contracted  adhesions  to  the  skin,  which  has  become 
reddened  and  broken  down  (fig.  126).  In  the  latter  case  the 
diagnosis  can  be  confirmed  by  bacteriological  examination  of  the  pus 
and  histological  investigation  of  a  piece  of  the  granulation  tissue. 

It  does  not  always  follow  that  a  cold  abscess  behind  or  near  the 
breast  really  originates  therein.  As  a  matter  of  fact,  it  more  frequently 
arises  from  a  rib.  If  the  lesion  of  the  rib  is  not  directly  accessible  to 
examination  we  must  depend  upon  the  absence  of  any  change  in  the 

breast  itself  to  sug- 
gest caries  of  the 
rib.  The  final  ver- 
dict must,  however, 
rest  with  a  skia- 
gram, which  may 
often  reveal  the  le- 
sion of  the  rib  quite 
distinctly. 

(6)  Tuberculosis 
of  the  breast  is  some- 
what similar  to  ac- 
tinomycosis, a  few 
cases  of  which  have 
been  recorded.  In 
the  latter,  however, 
the  glands  are  not 
enlarged,  and  the 
hard  infiltration  is 
very  distinctive.  If 
an  abscess  or  a  sinus  be  present  we  must  search  for  the  character- 
istic granules. 

The  diagnosis  of  gumma  of  the  breast  can  only  be  arrived  at  by 
exclusion  ;  and  is  confirmed  by  the  previous  history,  the  serum  test, 
and  the  result  of  specific  treatment. 

Very  rarely,  chronic  inflammatory  processes  which  do  not 
suppurate,  and  which  cannot  be  referred  to  any  of  the  causes  just 
mentioned,  occur  in  the  breast.  Chronic  cystic  mastitis,  which  we 
will  discuss  in  connection  with  tumours,  is  not  of  inflammatory 
origin. 


Fig.  126. — Tuberculosis  of  breast. 


TUMOURS    AND    ALLIED    STRUCTURES    IX    THE    BREAST 


22  ^ 


CHAPTER  XXXIII. 

TUMOURS  AND  ALLIED  STRUCTURES  IN 
THE  BREAST. 

The  breast,  like  other  glandular  organs,  is  often  the  seat  of 
structures  which  are  not  genuine  tumours,  but  which  are  not  sharplv 
differentiated  from  them.  They  have  nothing  to  do  with  bacterial 
mflammation.  As  the  epithelium  and  connective  tissue  are  both 
concerned  in  these  processes  they  are  best  designated  by  the  general 
term  of  libro-epithelial  degeneration.  Examples  of  this  morbid 
process  occur  in  the  thyroid  as  goitre,  and  in  the  prostate  as  hyper- 
trophy.    In  the  breast  the  following  types  mav  be  differentiated  : — ■ 

(a)  Preponderating  cyst  formation, 
either  as  a  solitary  cyst  or  as  a  con- 
glomeration of  small  cysts  (Reclus'  or 
Konig's  disease). 

{b)  Preponderating  proliferation  of 
the  connective  tissue  ;  formation  of 
so-called  fibro-adenoma  phvllodes. 

(c)  Preponderating  proliferation  of 
the  epithelium:  Fibro-adenomata  of 
purely  adenomatous  or  of  papillary 
character. 

All  these  changes  may  occur,  either 
in  a  diffuse  form  or  as  circumscribed 
encapsuled  tumours.  They  may  occur 
as  single  or  as  multiple  nodules,  and 
are  frequently  present  in  both  breasts. 
Sometimes  all  the  various  types  are 
combined  in  one  growth  ;  at  others, 
nodules  which  have  arisen  at  the  same 
time  in  both  breasts  may  manifest 
quite  different  characters.  Very  fre- 
quently, as  one  might  expect,  cancerous 
or  sarcomatous  degeneration  occurs. 
We  have  digressed  somewhat  into  these  pathological  details,  but  in  view 
of  the  existing  controversy  on  the  matter  this  was  not  superfluous.  We 
will  now  proceed  with  the  diagnosis  proper  of  tumours  of  the  breast. 

If  we  have  decided  that  a  sw^elling  of  the  breast  is  not  of  inflam- 
matory or  infective  origin,  and  therefore  regard  it  as  the  result  of 
fibro-epitJielial  degeneration,  or  as  a  genuine  neiv  groivth,  we  are  met 
with  the  great  question  of  innocence  or  malignancy — in  other  words, 
is  the  case  one  for  immediate  operation,  or  is  it  one  wherein  the 
advisability  of  operation  may  be  discussed  with  the  patient  ?  The 
precise  histology  of  the  disease  is  of  very  secondary  importance  in 
comparison  with  this  question  of  innocence  or  malignancy.  The 
first  point  to  ascertain  is  whether  the  tumour  is  single  or  multiple. 


Fig.   127. — Superficial  cyst  of  the 
breast. 


224 


SURGICAL   DISEASES   OF   THE   THORAX 


^.—MULTIPLE  TUMOURS. 
If  the  tumours  have  arisen  in  both  breasts  about  the  same  time,  or 
if  there  are  several  in  the  same  breast,  we  may  conclude  with  great 
probability  that  they  represent  the  innocent  process  of  fibro-epithelial 
degeneration.  But  in  order  to  establish  the  diagnosis  they  must 
possess  the  characteristics  to  be  described  in  the  following  section. 
It  is,  however,  quite  possible  for  one  nodule  of  an  originally  innocent 
fibro-adenoma  to  become  cancerous,  or  cancer  may  suddenly  burst 
forth    in     any    old    harmless    fibro-adenoma.       Unfortunately,    both 

patients  and  practitioners 
are  liable  to  forget  this 
possibility,  and  many  hesi- 
tate to  make  the  diagnosis 
of  cancer  because  some  old 
cysts  are  present,  either  on 
the  same  or  the  opposite 
breast. 

R— SINGLE  TUMOURS. 
We  will  divide  these  ac- 
cording to  their  size,  because 
the  questions  which  arise  in 
regard  to  them  vary  accord- 
ing to  their  dimensions. 

(1)  SMALL  AND  MEDIUM- 
SIZED  TUMOURS. 

We  begin  with  suiall  and 
iiiediuiii -sized  tumours,  i.e., 
those  which  do  not  exceed 
a  fist  in  size. 

The  fundamental  sign 
which  after  a  little  palpation 
almost  always  differentiates 
between  innocence  and  ma- 
lignancy is  the  movahility  of  the  tumour  in  relatiou  to  the  rest  of  the  breast 
tissue.  A  certain  amount  of  practice  is  required  to  estimate  this  mobility 
correctly,  but  it  can  be  acquired  by  the  attentive  examination  of  a 
few  cases.  An  index  finger  is  placed  on  each  of  two  points  on 
opposite  sides  of  the  tumour,  which  is  jerked  backwards  and  forwards 
between  them,  a  shaking  movement  being  imparted  to  it  at  the  same 
time.  If  the  tumour  yields  easily  to  this  manoeuvre  it  is  innocent 
If  this  mobility  is  absent  it  is  practically  conclusive  of  malignancy, 
even  if  the  growth   is    not    adherent  to  the  skin   or  to  the  pectoral 


Fig.  128. — Polycybtic  fibro-adenoma. 


TUMOURS    AND    ALLIED    STRUCTURES    IN   THE    BREAST  225 

fascia,  and  the  nipple  does  not  yet  show  any  indication  of  being 
drawn  in.  Only  an  inflammatory  attack  can  temporarily  deprive  an 
innocent  tumour  (cyst)  of  its  mobility.  If  pressure  is  made  on  the 
tumour  with  the  hand  flat  upon  the  chest  it  is  less  distinctly  felt  if  it 
IS  a  cyst,  whereas  if  it  is  cancer  it  is  more  distinctly  felt.  Whenever 
I  was  in  doubt  about  the  degree  of  mobility,  I  generally  found  at 
the  operation  that  the  tumour  was  malignant. 

Our  decision  must  never  be  influenced  by  the  patient.  Every 
surgeon  knows  of  cases  wherein  the  apprehensive  patient  considered 
her   harmless    cyst    to    be    a   cancer,    and    also    of   cases   wherein    a 


Fig.  129.— Early  scirrhus.     Nipple  drawn  up  and  slightly  "retracted. 

"hardening"  of  the  breast  has  been  shown  casually  to  the  medical 
attendant,  when  it  had  already  reached  the  limits  of  cure  by  operation. 
(a)  Having  decided  from  the  above  considerations  that  the  tumour 
is  innocent,  we  may  now  proceed  to  determine  to  which  of  the  fore- 
going anatomico-pathological  groups  it  should  be  ascribed.  If  the 
breast  is  diffusely  indurated  over  a  large  extent,  that  is  to  say,  if  it  has 
become  converted  into  a  conglomeration  of  small  hard  movable 
nodules,  the  case  is  one  of  the  formation  of  numerous  little  cvsts. 
Single  nodules  up  to  the  size  of  a  goose's  egg  are  either  cucapsuled 


226 


SURGICAL    DISEASES    OF   THE    THORAX 


fihro-adenouiata  or  solitary  cysts.  As  the  latter  do  not  show  any 
fluctuation  owing  to  their  extreme  tension,  the  clinical  differentiation 
is  often  impossible. 

Cysts  are  usually  indicated  by  variation  in  volume,  by  increase 
in  size  and  by  pains  during  menstruation  or  at  the  onset  of 
pregnancv,   and   bv  the    discharge    of    milky   fluid    from    the    nipple. 


Fig.    130.— Advanced  scinhus   with  retraction  and  elevation  of  nipple  and  diminution  in 

size  of  its  areola. 

A  brownish  or  sanious  secretion  especially  signifies  a  papillary  cyst, 
or  an  adeno-papilloma  developed  within  a  cyst,  which  stands  just  on 
the  border  line  of  malignancy  (so-called  "bleeding  breast,"  see  below). 
Superficial  cysts  have  a  bluish  transparency  and  fluctuation  is  often 
present  (fig.  127). 

If  the  nodule  exceeds  a 


oose's  egg  in  size  the  case  is  not  one  of 


TUMOURS   AND    ALLIED    STRUCTURES    IN    THE    BREAST 


227 


a  solitary  cyst,  but  is  some  form  of  encapsuled  fibro-adenoma,  or  the 
whole  breast  mav  have  become  changed  into  a  mass  of  multiple  cysts 
(fig-  128). 

We  have  hitherto  regarded  the  fact  that  a  tumour  is  freely  movable 
over  the  rest  of  the  breast  tissue    as  a  positive  sign   of*  innocence. 


Fig.  131. — Cancer  of  breast,  slightly  contracting,  situated  at  the  periphery.     Elevation 
and  retraction  of  nipple,  diminution  of  areola. 


But,  unfortunately,  there  are  exceptions.  A  primary  cancer  occa- 
sionally remains  quite  movable  for  a  long  time  ;  but  the  history  is 
distinctive  in  such  a  case.  If  the  tumour  has  only  been  present 
a   matter  of  months  it  is   probably   cancer  ;    if    for    a    year   or   more 


228 


SURGICAL    DISEASES    OF    THE    THORAX 


it  is  a  jfibro-adenoina.  Further,  fibro-adenomata  not  rarely  undergo 
cancerous  change,  and  this  alteration  is  not  signified  by  any  recog- 
nizable clinical  symptom.  For  this  reason  we  should  propose  to  the 
patient  the  removal  of  any  circumscribed  tumour,  however  innocent 
it  may  appear  to  be.  If  she  agrees,  the  growth  is  removed  while  the 
conditions  are  healthy,  or  better  still  the  whole  breast  is  shelled  out. 

The  excision  of  a  small  piece  of  a  mammary  tumour  for  diagnosis 
is  of  no  value,  for  the  piece  removed  may  happen  to  come  from 
a  portion  which  is  harmless,  whereas  a  cancerous  portion  may  still 
be  present.     The  following  case  indicates  the  difficulty  of  diagnosis  : — 

A  person,  aged  50,  noticed  a  small  movable  lump  in  each  breast. 
They  both  felt  alike,  were  diagnosed  as  cysts  and  removed.  Histo- 
logical examination  showed  that  the  tumour  on  the  right  side  was  an 
early  fibro-adenoma,  and  that  the  one  on  the  left  side  was  an  innocent 


Fig.  132.— Ulcerated  cancer  of  right  breast  in  patient  aged  65.  Apparently  a  cutaneous 
cancer  of  the  areola  (with  ulceration  above  and  to  inner  side  of  nipple),  but  really  a  con- 
tracting cancer  of  the  breast  with  elevation  of  nipple  and  diminution  of  the  areola. 


cyst.  The  latter  preparation  was,  however,  examined  again  some 
years  later,  and  a  circumscribed,  classical  infiltrating  carcinoma  a  few 
millimetres  in  size  was  noted  close  to  the  cyst.  Meanwhile,  enlarged 
glands  appeared  in  both  axillae,  and  after  their  removal  it  was  shown 
that  they  were — tubercular.  The  patient  came  from  a  tubercular 
stock. 

(b)  If  the  tumour  is  only  slightly  movable  or  quite  immovable  over 
the  rest  of  the  breast  tissue,  our  diagnosis  must  be  a  malignant 
growth,  especially  a  carcinoma,  even  if  the  ordinary  criteria  of  this 
disease  are  absent,  viz.,  retraction  and  elevation  of  the  nipple,  enlarged 


TUMOURS    AND    ALLIED    STRUCTURES    IX    THE    BREAST 


229 


glands  in  the  axilla,  and  adhesions  to  the  skin  and  pectoral  muscles. 
All  these  signs  eventually  make  their  appearance,  but  the  practi- 
tioner who  awaits  them  before  making  a  diagnosis  is  in  no  enviable 
position. 

Retraction  of  tlie  nipple  is  an  early  sign  only  in  the  contracting 
forms  of  cancer ;  but  it  sometimes  occurs  in  chronic  cystic  mastitis 
and  even  in  chronic  abscesses.  The  diminution  of  tlie  areola  around 
the  nipple  is  much  more  distinctive  of  cancer  (fig.  130),  and  the 
elevation  of  the  nipple  is  of  great  significance  (figs.  128  to  132)  because 
it  indicates  a  process  of 

contraction  and  points      r  ^  --'•=«•«'»:) 

to  cancer,    even    if  the      i  .      x,-  & 

nipple  itself  is  scarcely      '  '™"™™"  ' 

retracted  at  all  (fig.  129). 

Enlargement  of  the 
axillary  glands  occurs  in 
some  slight  degree  even 
in  the  case  of  innocent 
cysts,  and  nearly  always 
in  tubercular  disease. 
Tubercular  glands  are 
usually  softer  than  the 
malignant  variety  and 
break  through  the  skin 
sooner. 

Sarcoma  attacks  the 
glands  much  more 
rarely  than  carcinoma. 
The  difficulty  of  detect- 
ing early  cancerous  en- 
largement of  the  glands, 
in  fat  women,  is  fre- 
quently realized  first  at 
the  operation.  But  the 
demonstration  of  cancer- 
ous glands  lias  a  prognostic  rather  than  a  diagnostic  importance ; 
cancer  of  ttic  breast  can  and  must  be  recognized  icitiiout  ttieni. 

Exceptionally,  the  enlargement  of  the  glands  dominates  the  whole 
clinical  picture  and  the  cancer  itself  is  overlooked.  Thus,  a  patient, 
aged  47,  was  treated  for  eighteen  months  for  enlarged  moveable 
glands  in  the  left  axilla,  which,  according  to  the  family  history,  might 
have  been  tubercular.  This  diagnosis  was  apparently  supported  by 
the  occurrence  of  similar  glands  in  the  right  side  of  the  neck. 
Careful  examination,  however,  showed  that  there  was  on  the  left  side 
a  very  slight  induration   behind  the  nipple,  which  had  hitherto  been 


Fig.  133. — Small  contracting  cancer  in  the  fold  under 
the  breast. 


2^0 


SURGICAL    DISEASES    OF   THE    THORAX 


overlooked.       Histological    examination    of    the    breast    and   glands 
confirmed  the  diagnosis  of  cancer. 

Adhesion  to  the  pectoral  muscles  is  recognized  by  the  fact  that  the 
tumour  is  movable  when  the  muscle  is  relaxed,  and  that  it  appears 
to  be  immovable  when  the  muscle  is  contracted. 


n 


Fig.   134. — A   rapidly   breaking-down   cancer    of  breast.     The  whole  tumour  converted 

into  an  ulcer. 


We  have  not  yet  said  anything  about  jilccration,  because  this  does 
not  afford  any  fresh  material  for  diagnosis.  It  occurs  in  those  forms 
which  have  a  tendency  to  rapid  destruction  and  wherein  the  whole 
tumour  resembles  an  ulcer  (fig.  134),  and  also  in  the  scirrhous 
variety  wherein  the  skin  is  soon   involved,  especially  when  situated 


TUMOURS    AND    ALLIED    STRUCTURES    IN    THE    BREAST 


231 


near  the  nipple  (tig.  132)  or  in  the  fold  of  skin  at  the  lower  border 
of  the  breast  (fig.  133).  Finally,  almost  every  form  of  carcinoma 
will  naturally  ulcerate,  if  left  long  enough. 

The  small  contracting  cancers  of  the  nipple  (fig.  132)  and  those 
which  occur  in  the  fold  of  skin  under  the  breast  (tig.  133)  represent 
typical  forms.  Their  early  ulceration  and  their  whole  appearance 
lead  the  beginner  to  the  diagnosis  of  cancroid.  Thev  are  really 
cancers  of  the  breast  with  portions  deeply  situated,  and  on  palpa- 
tion they  are  recognized  to  be  much  larger  than  their  superficial 
appearance  suggests. 

If  an  eczematous  condition  of  the  nipple  and  its  vicinity  has  pre- 
ceded the  development  of  the  tumour  we  diagnose  the  well-known 
form  of  cancer,  termed 
Paget's  disease.  Every 
obstinate  eczema  in  this 
region  must  be  suspected, 
although  there  may  be 
no  tumour  present. 

The  only  constant 
sign  of  cancer  common 
to  all  forms  is  its  slight 
iiiobilifv  oil  file  healthy 
breast.  All  the  other  char- 
acteristics are  variable, 
and  there  are  numerous 
transitions  from  the  soft 
medullary  cancer  rich  in 
cells,  which  frequentlv 
attains  the  size  of  a  fist 
and  more  (tig.  135),  to 
the  contracting  scirrhus, 
poor  in  cells,  which  con- 
stitutes a  loss  of  tissue, 
although  it  is  actually  a 
growth  (figs.  1 29  and  1 30).      ^ 

Having  decided  upon 
the  diagnosis  of  cancer, 
the  matter  of  accurate  prognosis  claims  our  attention.  If  secondary 
growths  are  found  further  discussion  is  useless.  In  this  connection  the 
vertebral  column  should  be  thought  of,  and  it  is  worth  while  examining 
the  breast  in  cases  of  unexplained  sciatica  or  intercostal  neuralgia. 

A  patient  was  undergoing  electrical  treatment  for  several  months 
by  a  neurologist  for  lumbar  neuralgia.  Notwithstanding  the  sparks, 
there  was  no  illumination  of  the  breast  until  the  cancer  therein 
became  an  inoperable  scirrhus,  which  was  accidentally  discovered 
by  the  family  practitioner.     Paraplegia  soon  set  in. 


Fig.   135. — Medullary  cancer  of  breast. 


23' 


SURGICAL   DISEASES    OF    THE    THORAX 


There  are  three  other  signs  which  exclude  the  possibiHty  of  a 
complete  recovery,  and  these  must  be  considered  before  any  advice 
is  offered:  (i)  cidlicsiou  to  ilic  ribs;  {2')  the  presence  of  scaitcrcd 
cancerous  nodules  in  the  surrounding  skin  (fig.  136);  and  (3)  involve- 
ment of  the  supra-clavicular  glands.  If  there  are  any  indications  for 
an  operation  in  these  circumstances  it  can  only  be  one  for  relief  of 
local  symptoms. 

We  have  hitherto  limited  our  discussion  of  malignant  growths 
to  cancer,  and  have  said  nothing  about  sarcomata.  If  these  are  of 
an  infiltrating  type  from  the  commencement  they  are  indistinguish- 
able clinically  from  a  medullary  cancer.     All  that  we  have  said  about 

the  latter  applies  to  this 
form  of  sarcoma,  with  the 
exception  of  the  involve- 
ment of  the  lymphatic 
glands.  Encapsuled  sarco- 
mata, as  long  as  they  do 
not  exceed  a  list  in  size, 
are  only  distinguishable 
from  hbro-adenomata  by 
their  more  rapid  gro^vth. 
The  diagnosis  of  sarcoma 
is  of  more  importance  in 
regard  to  the  larger  tu- 
mours of  the  breast,  to 
which  we  will  now  turn. 


P'iG.  136. — Coniracling  cancer  of  breast,  with  numer- 
ous cancerous  nodules  in  the  surrounding  skin. 


(2)  LARGE  TUMOURS. 

A  huge  new  gfowth  of 
the  breast  niav  be  merely 
an  example  of  hypertrophy 
(giant  groictli),  and  then  it 
is  usually  bilateral.  Apart 
from  this  we  have  to  distingui-h  those  that  belong  to  the  class  of 
fibro-adenomata  on  the  one  hand — i.e.,  fibro-adenonna  or  cysto- 
adenoma  and  cysto-sarcoma  phvllodes — from  true  sarcomata  on 
the  other  hand.  Xotwith>tanding  the  modern  zeal  for  operation 
both  classes  are  still  responsible  for  cnoi-nioiis  tumours. 

Thus  a  patient  allowed  lier  tumour  (tig.  137)  to  attain  the  weight 
of  5^  kilos  and  to  become  extensivelv  putrefied  in  the  course  ot  a 
year  during  which  she  was  under  "nature  treatment."  That  the 
patient  eventuallv  became  intensely  cachectic  was  not  a  matter  ot 
surprise  considering  the  amount  of  putrefaction  and  the  dietetic  re- 
strictions which  she  underwent.     Nor  was  it  at  all  surprising  that  the 


TUMOURS   AND   ALLIED   STRUCTURES    IN   THE   BREAST 


"  nature-curer  "  claimed  the  credit  for  the  rehef  which  the  operation 
gave.  At  the  operation  the  growth  was  still  well  encapsuled,  and 
histologically  it  was  composed  of  a  typical  fibro-adenoma  with  some 
partial  sarcomatous  degeneration  of  the  stroma.  Two  years  after- 
wards the  patient  succumbed  to  multiple  metastases,  which  consisted 
histologically  of  pure  spindle-celled  sarcomata. 

Fibro-adenomata  or  cysto-adenomata  phyllodes,  as  well  as  the 
sarcomatous  degeneration  of  the  latter,  known  as  cysto-sarcomata 
phyllodes,  are  well  encapsuled  tumours,  which  only  ulcerate  if  the 
skin  over  them  becomes  tightly  stretched.  Metastases  occur  in  the 
sarcomatous  form,  but  more  rarely  than  in  the  case  of  piiniarv 
sarcoma  of  the  breast. 

The  latter  are  either  encapsuled  or  inHltrating,  and  occur  under 
the  most  varied  histological  forms.  Cystic  formation  also  takes  place 
in  these  cases,  but  not  as 
the  product  of  epithelial 
structures  as  in  cysto-sar- 
coma  proper,  but  as  the 
result  of  tissue  necrosis. 

If  the  tumour  shows 
no  infiltrating  growth  the 
differential  diagnosis  must 
be  based  on  the  history. 
If  it  has  been  present  for 
a  year  or  more,  and  has 
been  growing  regularlv 
or  bv  fits  and  starts,  the 
tumour  is  a  fibro-aden- 
oma. The  sudden  rapid 
growth  of  a  tumour 
which  has  been  quiet 
for  years  indicates  sarco- 
matous degeneration.  A 
tumour  of  wide  extent,  despite  short  duration,  is  a  pi-imarv  s;ircoma. 
A  word  must  here  be  said  about  the  "bleeding  breast."  The 
exudation  of  fluid,  varying  in  colour  from  brownish-red  to  pure 
blood-red,  either  spontaneously  or  on  pressure,  is  usually  a  sign  of 
tibro-epithelial  degeneration.  It  occurs  especially  when  papillomatous 
proliferations  are  present  in  cysts,  communicating  with  the  milk 
ducts.  The  symptom  is,  therefore,  not  so  serious  as  the  patient  usually 
imagines  ;  but  she  should  not  be  reassured  too  cnnfidentlv,  for  1  have 
also  seen  this  bleeding  in  cancer. 

In  this  case,  however,  there  were  some  iibro-epithelial  changes, 
innocent  cysts,  from  which  the  bleeding  obviously  emanated,  in 
addition  to  the  malignant  portion  of  the  growth.  But  the  historv 
indicated    that    the    luemorrhages    occurred    with    the    onset    of   the 


Fig.  137. — Fibro-adenoma  phyllodes  of  breast, 
broken  through  and  partially  undergone  sarcomatous 
degeneration. 


234  SURGICAL    DISEASES    OE   THE   THORAX 

carcinoma,  which  was   still  recent.       It  follows,  therefore,    that   the 
carcinoma  must  have  indirectly  excited  the  bleeding. 

As  examples  of  purely  innocent  tumours  of  the  breast,  there 
should  be  mentioned  lipoma,  which  is  rare,  and  chondroma,  which  is 
still  more  rare.  The  former  usually  occurs  near  and  not  //;  the  breast, 
and  is  recognized  by  its  softness,  just  as  the  latter  is  recognized  by  its 
cartilaginous  hardness.  The  whole  breast  seems  to  be  enlarged  in 
lipoma,  but  it  is  in  a  dependent  position,  just  like  the  healthy  breast. 
Finally,  it  should  be  stated  that  the  male  breast  may  be  affected  with 
anv  of  these  forms  of  tumour,  but,  according  to  Schuchart,  in  the 
proportion  of  i  to  lOO. 


PART   IV. 

SURGICAL  DISEASES  OF   THE 
ABDOMINAL  AND   PELVIC  VISCERA. 


CHAPTER    XXXIV. 
DISPLACEMENTS    OF  THE    ABDOMINAL   VISCERA. 

The  accuracy  of  the  topographical  diagnosis  of  abdominal 
diseases  depends  upon  the  assumption  that  the  viscera  occupy  their 
normal  position.  But  this  is  not  always  the  case.  All  the  abdominal 
viscera  are  liable,  in  more  or  less  degree,  to  displacements,  some  of 
which  date  from  birdi,  while  others  are  acquired  in  later  life. 

A. — We  may  begin  with  the  congenita!  displacements.  The  only 
paired  viscera  in  the  abdominal  cavit}' — the  kidneys — are  occasionally 
subject  to  pecuHar  conditions. 

The  kidneys,  for  example,  may  be  fused  together  and  lie  in  front 
of  the  spine,  in  the  shape  of  a  horse  shoe  or  a  cake.  They  may  also 
be  fused  together  at  their  extremities  and  lie  on  the  same  side,  one 
above  the  other.  If  one  kidney  is  entirely  absent,  the  other  is 
abnormally  large.  Congenital  displacement  of  one  or  both  kidneys 
into  the  pelvis  is  of  still  greater  importance  diagnosticallv.  Some- 
times the  displaced  kidney  lies  at  the  side,  sometimes  it  is  in  the 
middle ;  occasionally  it  is  found  in  the  false  pelvis,  at  other  times 
even  in  the  true  pelvis.  With  the  methods  accessible  to  the  practi- 
tioner, it  is  impossible  to  diagnose  these  anomalies  with  any  certainty  ; 
more  especially,  as  such  kidneys  do  not  exhibit  the  mobility  of  the 
ordinary  movable  kidneys,  nor  are  thev  capable  of  being  replaced 
into  their  normal  position.  Therefore  in  operating  upon  a  "tumour 
of  the  adnexa,"  the  diagnosis  of  which  is  not  clear,  it  is  alwa3's  desir- 
able to  think  of  the  possibility  of  this  condition.  The  significance 
of  a  mistake  in  connection  with  a  displaced  solitary  kidney  need  not 
be  mentioned. 

i6 


236       SURGICAL    DISEASES    OF   THE    ABDOMINAL   AND    PELVIC   VISCERA 

These  cases  can  only  be  clearly  distinguished  by  skiagraphy  com- 
bined with  catheterism  of  the  ureters,  or,  better  still,  by  a  skiagram 
taken  after  the  renal  pelvis  has  been  filled  with  collargol. 

The  fundamental  variety  of  displacement  of  the  iinpaircd  abdominal 
organs  is  the  "typus  inversus."  This  is  comparatively  easily  detected 
on  clinical  examination,  provided  the  thoracic  viscera  are  affected  in 
the  like  manner.  But  if  the  displacement  only  concerns  the  abdominal 
organs,  it  is  very  likely  to  be  overlooked,  although  palpation  and 
percussion  wovild  probably  reveal  the  rare  cases  wherein  the  positions 
of  the  liver  and  spleen  are  reversed.  A  doubtful  case  is  immediately 
cleared  up  by  a  skiagram,  because  the  position  of  the  stomach  is  also 
reversed  in  these  circumstances. 

Displacement  of  the  intestiiu  alone  is  much  more  frequent  and 
therefore  of  greater  surgical  importance. 

The  following  are  the  chief  varieties  which  have  been  dis- 
tinguished : — 

(i)  The  large  intestine  lies  in  its  whole  extent,  behind  flic  small 
intestine,  because  of  the  failure  of  the  umbiUcal  loop  to  revolve 
(retroposition).  The  mesentery  may  either  be  free  or  may  contract 
adhesions  with  the  posterior  abdominal  wall. 

(2)  The  entire  large  intestine  lies  on  the  left  side  of  the  abdomen 
because,  although  the  umbilical  loop  has  revolved  in  the  right 
direction,  it  has  failed  to  do  so  completely,  i.e.,  to  the  extent  of 
permitting  decussation  of  the  small  and  large  intestine  {sinistro- 
position).  The  mesentery  may  either  be  free  or  may  have  contracted 
secondary  adhesions.  In  the  former  case  both  small  and  large 
intestine  are  connected  with  a  free^  common  mesentery,  the  so-called 
mesenterinm  commnnc. 

(3)  The  entire  large  intestine  is  in  the  right  half  of  the  abdomen, 
because  the  umbilical  loop  has  incompletely  revolved  in  the  wrong 
direction  {dextro-position) .  The  condition  of  the  mesentery  is  as  in 
No.  2. 

(4)  There  has  been  complete  decussation  of  the  small  and  large 
intestine,  but  in  a  reversed  position,  because,  although  the  umbilical 
loop  has  revolved  completely  the  direction  has  been  wrong  [situs 
inversus  abdominaUs  partialis  inferior). 

These  are  the  extreme  varieties,  but  a  much  more  frequent  abnor- 
mality is  one  which  we  may  regard  as  an  intermediate,  form  between 
the  normal  position  and  the  left-sided  position  of  the  large  intestine, 
with  free  mesentery.  Here  the  caecum  and  ascending  colon  possess  a 
free  mesentery,  which  merges  with  that  of  the  lowest  coil  of  the  small 
intestine.  At  the  same  time  the  ascending  colon  is  frequently 
shortened,  so  that  the  caecum  is  abnormally  high.  If  there  is  no 
ascending  colon  at  all,  and  the  caecum  lies  directly  against  the  border 
of  the  liver,  we  are  wiihin  the  border  line  of  a  left-sided  position. 
We  can  tell  this  at  a  glance  when  the  caecum  is  so  far  displaced  to  the 
left  that  the  large  and  small  intestine  no  longer  decussate.  The 
significance  of  this  abnormahty  may  be  gathered  from  the  fact  that 


DISPLACEMENTS    OF    THE    ABDOMINAL    VISCERA 


^37 


it  is  found  in  its  mildest  form — incsciitciiuiu  comninnc  ileo-ccvcalc — in 
lo  per  cent,  of  all  autopsies.  The  more  pronounced  variety  has 
certainly  been  encountered  by  all  surgeons  during  the  performance 
of  laparotomies. 

There  are  two  matters  to  which  practical  importance  attaches  in 
connection  with  these  displacements  :  (i)  The  position  of  tlie  appendix, 
and  (2)  the  question  of  the   decussation   of  small  and  large  intestine. 

Let  us  begin  with  the  appendix. 

Whereas  this  may  lie  in  the  true  pelvis  in  cases  of  enteroptosis 
or  when  the  caecum  is  abnormally  long,  it  may  be  found  high  np 
in  front  of  the  right  kidney,  at  the  edge  of  the  liver,  or  even  under 
the  liver  close  to  the  gall  bladder  in  cases  of  shortening  of  the 
ascending  colon,  which  are  so  often  associated  with  a  free  mesentery 
of  the  ileo-caecal  coil.  I  have  found  it  in  all  these  situations  during 
laparotomy.  The  more  free  the  ileo-caecal  coil,  the  nearer  it  will 
be  to  the  middle  line.  When  the  large  intestine  is  displaced  to  the 
left,  it  usually  lies  in  the  umbilical  region  or  even  to  the  left  of  it. 
In  complete  transposition  it  is  found  in  the  left  side  of  the  pelvic 
cavity.  In  this  condition  the  entire  position  of  the  intestine  is  that 
of  the  normal,  as  seen  in  a  mirror.  It  follows,  therefore,  that  the 
appendix  has  made  a  complete  ciicuit  of  the  abdomen,  and  we  must 
be  prepared  to  meet  with  it  anywhere. 

The  matter  of  the  decnssation  of  the  small  and  large  intestine  is  not 
so  much  one  of  diagnostic  interest  as  of  technical  importance  for 
operation.  In  all  cases  of  incomplete  revolving  of  the  umbilical 
coil  with  a  free  mesentery  this  decussation  is  absent.  This  demands 
special  notice  because  it  is  customary  in  performing  gastro-enteros- 
tomy  to  search  for  the  highest  coil  of  small  intestine,  where  it  comes 
out  under  the  transverse  colon.  If,  on  opening  the  abdomen,  the 
position  of  the  intestine  shows  that  decussation  has  not  taken  place, 
we  must  follow  the  duodenum  in  order  to  find  the  highest  coil  of 
jejunum.  In  cases  wherein  the  large  intestine  is  on  the  left,  the 
duodenum  winds  towards  the  region  of  the  right  kidney,  and  thence 
passes  into  the  jejunum  in  the  vicinity  of  the  right  side  of  the  pelvis. 

Besides  these  typical  displacements,  there  are  other  rarer  anomalies 
which  do  not  admit  of  classification,  and  are  only  accidentally  recog- 
nized in  a  skiagram  or  discovered  during  an  operation.  The  intestinal 
displacements  caused  by  diaphragmatic  hernia  belong  to  this  group. 

On  one  occasion  the  transverse  colon  was  found,  drawn  up  as  far 
as  the  ensiform  process  and  held  tightly  there,  by  means  of  the 
omentum,  which  was  involved  in  a  congenital  diaphragmatic  hernia 
into  Morgagni's  space. 

Even  the  typical  displacements  previously  referred  to  cannot  be 
diagnosed  clinically  without  the  aid  of  a  skiagram.  We  shall  discuss 
the  technique  connected  therewith  later  on. 

B.  Acquired  displacements  of  the  abdominal  organs  are  grouped 


238       SURGICAL   DISEASES   OF   THE   ABDOMINAL   AND    PELVIC   VISCERA 

together  under  the  term  of  enteroptosis.  French  chnicians  have  been 
famihar  with  this  condition  for  many  years,  but  a  due  prominence  has 
lately  been  given  to  it  by  Stiller.  In  regarding  it,  however,  as  a 
symptom  of  '' asthenic  constitutional  disease,"  he  merely  paraphrases 
his  observations  and  does  not  explain  the  pathology  of  the  condition. 
We  do  not  really  possess  any  genuine  explanation  of  the  clinical 
picture  presented  by  enteroptosis,  and  we  will  therefore  not  enter  here 
into  the  discussion  of  theories.  We  shall  only  refer  to  the  symptom- 
ology  of  those  forms  which  are  of  diagnostic  importance,  leaving  the 
clinical  details  to  the  chapters  dealing  with  the  individual  organs. 

Even  the  public  are  aware  that  the  kidney  may  be  movable,  and 
floating  kidneys  which,  a  few  decades  ago,  were  unknown  to  medical 
men,  have  now  become  the  common  property  of  the  civilized  world. 
Every  practitioner  recognizes  the  oval  swelling  which  descends  from  the 
hypochondrium  with  each  inspiration,  and  remains  fixed  in  that  position, 
but  is  capable  of  again  being  displaced  under  the  ribs,  by  pressure. 

Similarly  but  much  more  rarely,  the  liver  and  spleen  become  mov- 
able. But  whereas,  a  movable  liver  is  due  to  general  relaxation  of  the 
suspensory  ligaments,  a  movable  spleen  depends  upon  some  morbid 
enlargement  of  the  organ. 

The  downward  displacement  of  the  spleen  is  thus  the  only 
acquired  visceral  malposition  which  depends  upon  some  morbid 
condition  of  the  organ  itself  rather  than  upon  weakness  of  its  sus- 
pensory ligaments. 

A  movable  spleen  is  easily  recognized  by  its  sharp  anterior  border, 
and  by  the  fact  that  the  splenic  dulness  is  absent  from  its  normal 
situation. 

This  sharp  border  serves  as  a  guide,  if  the  spleen  is  situated  at  a  dis- 
tance from  its  normal  position.  I  had  a  case  of  a  young  lady  who  was 
sent  to  Europe  from  a  malarial  country  on  account  of  an  "  ovarian 
tumour."  She  had  a  tumour,  occupying  the  right  half  of  the 
abdomen  and  the  tnic  pelvis,  which  presented  on  the  right  side  a 
remarkably  sharp  border.  The  normal  splenic  dulness  was  absent. 
This  sufficed  for  the  diagnosis  of  a  movable  spleen,  and  the  heavy 
organ,  weighing  two  and  a  half  kilos,  was  removed.  The  pedicle  of 
the  spleen  was  drawn  out  over  the  transverse  colon,  and  ran  down- 
wards to  the  right. 

We  must  consider  ptosis  of  the  stomach  and  of  the  intestine,. 
together,  not  only  because  of  their  clinical  connection,  but  also 
because  they  are  recognized  by  the  same  diagnostic  methods.  We 
shall  begin  with  palpation. 

It  has  long  been  known  that  palpation  of  the  kidneys,  liver  and 
spleen  renders  definite  indications  for  the  diagnosis  of  acquired 
ptosis,  but  it  was  not  appreciated  that  indications  of  ptosis  of  stomach 
and  intestine  might  be  obtained  in  the  same  way.  Glenard  and  his 
school  have  indeed  been  teaching,  for  the  last  tw^enty-five  years,  how 


DISPLACEMENTS   OF   THE   ABDOMINAL   VISCERA  239 

to  palpate  the  large  intestine.  They  erred,  however,  in  their  view  that 
only  a  diseased,  or  at  any  rate  a  morbidly  contracted  large  intestine 
is  palpable.  This  error  has  been  exposed  by  Obrastzow,  who  has 
shown  that  a  considerable  portion  of  the  course  of  the  large  intestine, 
and  also  a  certain  portion  of  the  normal  stomach,  can  be  demonstrated 
by  palpation,  even  in  health.  This  has  been  confirmed  by  all  who 
have  worked  systematically  at  the  subject.  The  frequency  with  which 
one  section  or  other  of  intestine,  or  portion  of  stomach,  can  be 
palpated,  depends  not  only  upon  the  experience  of  the  examiner,  but 
also  upon  the  clinical  material  available.  Patients  suffering  mainly 
from  medical  diseases  (Hausmann)  will  yield  a  higher  percentage  of 
positive  results  than  those  suffering  from  surgical  affections,  because 
the  latter  group  will  include  many  cases  of  meteorism  and  in- 
flammatory diseases.  The  greatest  care  must  be  taken  not  to  perform 
any  systematic  palpation  of  the  individual  portions  of  the  intestine,  if 
there  is  the  slightest  risk  of  causing  any  damage,  e.g.,  in  all  recent 
acute  inflammations  of  the  biliary  passages,  the  appendix  or  the 
bowel.  It  is  much  better  to  remain  in  doubt  in  regard  to  the  course 
of  the  intestine,  than  to  burst  an  encapsuled  abscess,  or  to  rupture  an 
appendix  which  is  threatening  to  perforate. 

.    What  are  we  able  to  feel  through  a  relaxed  abdominal  wall,  which 
is  not  too  fat  ? 

(a)  Every  portion  of  the  digestive  canal  which  contracts  upon  its 
contents,  against  an  obstruction  (gastric  and  intestinal  rigidity). 

(6)  The  large  intestine,  even  if  it  contracts  in  an  empty  state  {la 
corde  coUqiie)  or  when  it  is  filled  with  faeces. 

(c)  Any  section  of  bowel,  even  if  empty,  which  can  be  rolled,  in  a 
localized  manner,  on  a  firm  underlying  surface. 

This  leads  us  to  the  following  conclusions  as  far  as  the  various 
sections  of  the  gastro-intestinal  canal  are  concerned  (see  also  fig.  138). 

In  the  stomach,  the  pyloric  region  can  be  felt  if  it  is  not  overlain 
by  the  liver  ;  and  the  greater  curvature,  if  it  is  not  too  low  down,  on 
account  of  ptosis.  If  the  stomach  has  dropped  considerably,  the 
pancreas,  which  undergoes  less  displacement,  may  often  be  felt  lying 
transversely  in  front  of  the  vertebral  column. 

In  regard  to  the  small  intestine,  it  is  only  possible  to  feel  the 
termination  of  the  last  coil  where  it  opens  into  the  caecum,  even  in 
the  most  favourable  circumstances,  as  Hausmann  correctly  remarks. 

It  is  very  rarely  possible,  if  at  all,  to  feel  the  appendix  in  normal 
conditions.  The  termination  of  the  final  portion  of  the  small 
intestine  (Hausmann)  or  as  I  would  suggest,  at  any  rate  its  lower 
border,  is  often  felt  and  this  is  assumed  to  be  the  appendix.  In 
pathological  conditions,  a  mass  formed  of  appendix  and  adherent 
omentum,  and  frequently  also  of  adjoming  coils  of  intestine,  is  often 
taken  to  be  the  appendix. 

In  most  patients  it  is  possible  to  feel  the  ca3cum  and  the  ascending 
colon,  almost  as   far    as   the  hepatic  flexure,  and  in  the  majority  of 


240      SURGICAL   DISEASES   OF   THE   ABDOMINAL   AND    PELVIC   VISCERA 


patients  the  descending  colon  is  palpable  together  with  the  upper 
segment  of  the  sigmoid  flexure.  We  are  sometimes  able  to  feel  the 
beginning  of  the  transverse  colon,  to  the  inner  side  of  the  ascending 
colon,  and  its  end,  to  the  inner  side  of  the  descending  colon.  But 
the  main  portion  of  the  transverse  colon  is  only  palpable  when  it  is 
sufliciently  high  above  the  symphysis  to  permit  of  its  being  rolled  on 
the  vertebral  spine,  and  if  the  patient  is  not  fat  and  the  small  intestine 
only   slightlv   filled.     This   combination    of    circumstances    does    not,. 

however,  often  occur.  A 
transverse  colon  which 
does  not  lie  too  low,  and 
which  is  in  a  condition 
of  spastic  contraction  can 
always  be  felt,  but  the 
renal  flexure  of  the  large 
intestine  can  practically 
never  be  palpated. 

Although  palpation 
aft'ords  many  indications 
as  to  the  position  of  in- 
dividual portions  of  the 
bowel,  the  results  obtained 
by  this  method  do  not 
equal  in  reliability  those 
which  are  furnished  by  a 
skiagram. 

A  prehminary  word  in 
regard  to  method.  It  is 
simple  enough  as  far  as 
the  stomach  is  concerned. 
Changes  in  position  are 
visible  immediately,  upon 
the  screen  or  upon  the 
plate,  if  the  patient  is  ex- 
amined directly  after  taking 
the  appropriate  contrast- 
forming  meal  {see  under 
"Diseases  of  Stomach"). 
In  regard  to  the  large  intestine,  the  most  suitable  procedure 
would  appear  to  be  that  of  injecting  some  contrast-forming,  thin 
fluid  emulsion,  on  the  same  principle  as  the  old  practice  of  distending 
the  rectum  with  gas,  or  filling  it  with  water — and  this  method  has 
been  largely  employed.  But  it  is  becoming  quite  clear  that  the  filling 
of  portions  of  the  bowel,  which  are  intended  to  hold  rather  solid 
contents,  with  large  quantities  of  liquid  produces  unnatural  distortions 
thereof.  However  useful  this  procedure  may  be  for  some  purposes,  it 
can  only  present  a  caricature  of  the  normal  shape  of  the  bowel  {see 


Fig.  138. — Diagrammatic  representation  of  the 
abdominal  organs  wliich  can  most  frequently  be  felt. 
(l)  Liver ;  (2)  Right  kidney  ;  (3)  Greater  curvature 
of  the  stomach  ;  (4)  Csjcum  and  ascending  colon  ; 
(5)  Beginning  of  transverse  colon  ;  (6)  End  of  trans- 
verse colon  ;  (7)  Descending  colon  and  upper  segment 
of  sigmoid  flexure. 


DISPLACEMENTS    OF    THK    ABDOMINAL   VISCERA 


241 


fif^s.  i39«  and  139&).  A  better  conception  of  the  position  of  the  large 
intestine  can  be  obtained  by  giving  the  contrast-forming  meal  by  the 
stomach,  and  then  following  its  progress  through  the  intestine  by 
means  of  screen  examinations  or  plate  impressions.  It  is  as  a  rule 
sufficient  to  take  impressions  after  six  to  eight  hours,  and  after  twenty- 
four  hours,  and  again  after  forty-eight  hours  if  there  is  any  unusual 
sluggishness  of  intestinal  movements,  in  order  to  draw  a  correct 
conclusion  as  to  the  position  of  the  whole  large  intestine.  The  older 
methods  of  distension  and  injection  of  water  are  quite  unreliable,  and 
they  had  better  be  discarded  as  a  means  of  diagnosing  the  position  of 
the  large  intestine. 


Fig.  139a.— Skiagram  of  large  intestine, 
twenty-four  Imurs  after  taking  tlie  bismuth 
meal.     Normal  position  and  shape. 


Fig.  l^<)b.  —  Skiagram  of  same  case  after 
bismuth  injection,  showing  distortion  in 
position  and  shape. 


The  X-rays  examinations  have  clearly  pointed  out  what  the  essential 
feature,  is  in  the  diagnosis  of  visceral  displacements.  Thus,  in  the 
stomach  neither  a  low-lying  greater  curvature,  nor  the  position  of  the 
smaller  curvature,  which  usually  runs  in  a  vertical  direction,  is  of  so 
much  importance  as-  the  position  of  the  pylorus.  A  flabby  weak 
stomach  may  become  temporarily  distended  to  a  low  level  from  the 
pressure  of  its  semi-solid  contents,  without  the  pylorus  necessarily 
having  been  dragged  down.  A  case  should  only  be  regarded  as  one 
of  genuine  ptosis,  when  the  skiagram  shows  that  the  pyloric  orifice 
has  been  displaced  downwards  {sec  fig.  140). 


242       SURGICAL    DISEASES    OE    THE    ABDO.MIXAL    AXD    PELVIC    VISCERA 

The  position  of  the  transverse  colon  was  always  looked  upon  as 
the  criterion,  as  far  as  the  large  intestine  was  concerned,  and  this  still 
holds  good.  Skiagraphv  has,  however,  shown  that  the  transverse 
colon  may  reach  down  as  far  as  the  true  pelvis  in  consequence  of  its 
great  development  in  length,  without  there  being  any  visceral  ptosis — 


Normal  stomach.  Ab- 
dominal position.  Bull's 
horn  shape. 


Normal  stomach.     Right 
side  position. 


Normal  stomach.     Same 
case.     Abdominal    posilion. 


Normal  stomach.      Same 
case.  Standing  position. 


Slight  degree   of  ptosis. 
Standing  position. 


Extreme  degree  of  ptosis. 
Standing  position. 


Fig.   140. — Semii-diagrammatic  representation  of  the  more  imporlant  shapes  and   positions  of 

the  stomach. 


a  confirmation  of  a  fact  previou>ly  known,  hut  to  which  litlle  attention 
was  paid.  Displacement  of  botli  flexures  is  of  greater  importance; 
it  is  seen  in  its  most  marked  form  in  the  hepatic  flexure,  because  of 
the  greater  mobility  of  the  right  kidney.  The  left  flexure,  like  the  left 
kidney,  does  not  descend  ^o  low,  even  in  pronounced  ptosis.     These 


DISPLACEMENTS    OP^    THE    ABDOMIXAL    VISCERA 


243 


conditions  can  only  be  recognized  ni  a  skiagram,  witli  complete 
certainty.  This  shows  that  the  position  of  the  transverse  colon  varies 
considerablv  in  the  same  patient,  with  the  different  conditions  of 
contraction  which  it  may  present — a  point  which  confirms  results 
which  can  also  be  obtained  from  palpation. 


Transverse  course  of 
transverse  colon. 


Descending  course  of 
transverse  colon. 


Ascending  course  of 
transverse  colon. 


Dependent  position  of 

transverse  colon,  rather  low 


Same   case,    with   low 
position  of  flexures. 


Dependent      position     of 
transverse    colon,   very    low. 
Flexures  at  normal  level. 
Fig.   141. — Semi-diagrammatic  representation  of  the  more  important  shapes  of  large  intes- 
tine.    Taken  mostly  twenty-four  hours  after  administration  of  contrast-forming  substance  per  os. 


TJie  criteria  fnynislied  by  skiagrapliy  in  regard  to  gastro-  and  cntcro- 
piosis  may  be  briefty  simunarizcd  as  follows :  Low  level  of  the  greater 
curvature  aud  pylorus,  loiv  level  of  hepatic  flexure,  and  very  frequently 
an  encroachment  of  the  ccecuni  beyond  the  linea  inominata  down  into 
ihe  true  pelvis. 


244      SURGICAL    DISEASES    OF    THE    ABDOMINAL   AND    PELVIC    VISCERA 

Although  these  are  all  matters  of  no  slight  diagnostic  interest  it 
does  not  follow  that  enteroptosis  affords  a  successful  field  for  thera- 
peutic activity.  Xearlv  all  the  abdominal  organs  have  been  stitched  up^ 
and  the  statement  has  been  made  that  all  the  viscera  can  be  restored  to 
their  normal  position.  This  may  be  true  anatomically,  but  we  cannot 
ascribe  all  the  numerous  discomforts  of  '' des  eqiiilihris  dii  ventre, 
raerelv  to  the  visceral  displacement.  Defective  innervation  of  the 
digestive  organs  must  bear  some  of  the  blame.  This,  of  course,  does 
not  exclude  the  possibility  of  a  vicious  circle  arising  in  certain  cases, 
due  to  primary  disturbance  of  function  on  the  one  hand,  and  change 
in  form  and  position  on  the  other  hand — a  circle  which  can  only  be 
broken  by  operative  interference.  But  these  are  the  exceptional  cases^ 
and  the  surgeon  is  always  anxious  to  participate  with  the  physician 
in  their  treatment,  however  anxious  the  patient  may  be  for  operation. 


CHAPTER  XXXV. 

ABDOMINAL  INJURIES. 

From  the  surgical  standpoint  abdominal  injuries  demand  careful 
examination,  early  diagnosis,  and  rapid  decision.  Lives  are  constantly 
sacriticed  because  diagnosis  is  delayed  until  tlie  complete  clinical 
picture  of  peritonitis   is  developed. 

.4.__IXJURIES  WITHOUT  AX  OPEN  WOUND. 

The  cases  wherein  violence  has  produced  no  open  wound  present 
the  greatest  ditticulties,  because  we  rarely  know  the  precise  spot  of 
the  application  of  the  force,  and  therefore  the  range  of  possible 
organs  involved  is  much  larger  than  in  cases  of  perforating,  incised, 
or  gunshot  wounds.  It  is  therefore  necessary  in  every  case  to 
examine  all  the  abdominal  organs,  for  nothing  is  more  fatal  than  to 
overlook,  for  instance,  a  rupture  of  the  bowel  in  a  case  wherein  a 
renal  injury  is  the  predominant  clinical  feature.  In  examining,  we 
must  think  first  of  the  most  urgent  danger  which  is  liable  to  follow 
these  injuries,  i.e.,  luenwrrliage.  If  we  can  exclude  this,  we  next 
investigate  for  rupture  of  the  gastro-intestinal  tract,  and  finally  for  an 
effusion  from  one  of  the  hoUoiv  viscera,  such  as  the  gall  bladder 
or  urinary  bladder. 


ABDOMINAL   INJURIES  2-|5 

(1)  GASTRO-INTESTINAL  CANAL. 

If  the  injury  has  merely  been  a  contusion,  there  may  be  no  severe 
symptoms  at  first,  except  the  initial  shock.  The  injury  may  only  be 
recognized  from  blood  appearing  in  the  stools,  or  by  symptoms  of 
slight  intestinal  obstruction  coming  on  after  two  or  three'days. 

Similar  symptoms  will  be  caused  by  injury  to  the  portion  of 
mesentery  in  contact  with  the  bowel,  or  by  a  clean  detachment  of 
the  mesentery  from  a  coil  of  intestine,  if  circulatory  disturbances 
short  of  gangrene  have  been  produced  in  the  intestinal  wall.  If  the 
extent  of  mesenteric  detachment  has  exceeded  two  centimetres,  gan- 
grene will,  however,  not  usually  be  long  in  appearing. 

In  a  case  of  rupture,  the  injury  is  not  as  a  rule  narrowly  circum- 
scribed, as  with  a  gunshot  or  perforating  wound.  There  is  usually 
laceration  of  a  considerable  part  of  the  circumference  of  the  in- 
testine, or  even  a  whole  loop  may  be  completely  torn  through.  The 
entrance  of  gas  into  the  abdoininat  cavity  is  therefore  much  more 
likely  when  the  injury  has  produced  no  external  wound  than  in  the 
case  of  a  gunshot  or  perforating  wound.  But  if  the  intestine  was 
empty  at  the  time  of  the  injury  this  symptom  cannot  always  be 
demonstrated. 

One  must  never  assume  that  there  is  no  free  gas  in  the  abdominal 
cavity,  as  is  often  done,  because  the  liver  dulness  is  still  present. 
The  amount  of  free  gas  maybe  very  small,  and  in  that  case  it  would 
only  show  itself  in  the  highest  point  of  the  abdomen  by  its  very 
tympanitic  or  metallic  note,  and  by  its  change  of  situation  with  the 
altered  position  of  the  patient.  These  two  signs  are  so  reliable,  and 
their  method  of  demonstration  so  harmless,  that  we  may  entirely 
abandon  puncture,  as  a  test  for  the  presence  of  gas  in  such  cases. 

The  following  case  is  instructive  in  this  connection  :  A  young 
man  was  caught  between  the  buffers  of  two  locomotives,  and  was 
brought  to  the  hospital  two  and  a  half  hours  later.  The  liver  dulness 
w^as  still  present.  The  pulse  was  quiet — 80  per  minute — temperature 
and  general  appearance  normal.  But  there  were  spontaneous  pains 
and  tenderness  on  pressure  in  the  epigastrium  and  in  the  left 
hypochondrium.  The  abdominal  muscles  were  reflexly  contracted. 
On  percussion  there  was  dulness  in  the  lumbar  regions,  extending 
lower  on  the  left  than  on  the  right.  Liver  dulness  was  present,  but 
careful  percussion  elicited  a  metallic  note  over  a  very  limited  area  in 
the  region  of  the  ensiform  process.  When  the  patient  was  turned  to^ 
the  right  the  metallic  note  shifted  to  the  left;  when  he  was  turned 
again  on  to  his  back  it  returned  once  more  beneath  the  ensiform 
process.  The  patient  vomited  once.  Diagnosis:  injury  to  intestine 
when  comparatively  empty,  with  exit  of  an  insignificant  amount  of 
gas  which  occupied  the  highest  portion  of  the  abdominal  cavity. 
Immediate  operation  was  undertaken,  which  revealed  a  loop  of  the 
jejunum  torn  transversely.     This  was  sutured  and  recovery  followed.. 

This  movable  metallic  note,  which  is   demonstrable  immediately 


246       SURGICAL    DISEASES    OF    THE    ABDOMIXAL    AND    PELVIC    VISCERA 

after  the  injurv,  must  not  be  confused  Avith  a  similar  change  m  note 
which  occurs  later  on  in  the  vicinity  of  the  injured  coil,  and  which  is 
immovable.  This  latter  is  due  to  local  meteorism,  consequent  upon 
inflammatorv  changes.  Neither  must  it  be  confused  with  the  collec- 
tions  of  gas  which  form  in  the  free  abdominal  cavity,  or  in  encapsuled 
abscesses  later  on  in  the  course  of  peritonitis.  In  soine  cases  there 
is  no  exit  of  gas  at  all,  as  I  have  mvself  seen  in  a  case  wherein  there 
were  three  complete  transverse  rents.  This  is  especially  true  of 
ruptures  of  the  jejunum;  and  in  these  cases  the  diagnosis  must  be 
based  on  the  symptoms  to  be  subsequently  discussed. 

The  presence  of  diihicss  is  of  uncertain  value  in  diagnosis.  When 
the  intestine  is  empty,  a  portion  of  the  abdominal  cavity  is  often  dull, 
even  under  normal  conditions,  especially  the  left  hypochondrium  and 
the  hypogastrium.  Even  if  the  dulness  is  to  be  attributed  to  the 
injury,  it  might  just  as  well  be  due  to  blood  as  to  an  effusion  of  gastric 
or  intestinal  contents.  Pronounced  defense  niusculaire  points  to  the 
effusion  of  intestinal  contents,  but  slight  muscular  contraction  is 
rather  in  favour  of  haemorrhage.  Striking  pallor  points  to  haemor- 
rhage, and  if  cyanosis  begins,  it  is  probable  that  the  intestine  has  been 
ruptured. 

If  there  is  nothing  suspicious  on  tht  tirst  examination  we  should 
wait,  watching  the  patient  carefully,  examining  him  again  and  again  at 
short  intervals.  If  the  condition  becomes  at  all  worse  it  must  arouse 
grave  suspicion.  If  a  widespread  contraction  of  the  abdominal  wall 
persists,  associated  with  tenderness  on  pressure  and  pain  on  deep 
inspiration,  then  the  more  certain  can  we  be  of  an  intestinal  injury 
the  more  circumscribed  were  the  limits  of  the  contusion.  Thus 
experience  shows  that  ruptures  of  the  intestine  are  especially  frequent 
after  kicks  with  a  hoof.  //  must  again  be  emphasized  thai,  in  this  eariy 
stage,  one  must  not  expect pincliedfeatnres,  dry  tongue,  distended  abdomen 
or  thread-like  pulse,  even  if  the  injury  lias  been  severe.  Vomiting  may 
even  be  completely  absent. 

We  may  summarize  our  diagnostic  reflections  in  the  following 
sentence:  //'  a  patient,  a  few  hours  after  an  abdominal  contusion,  has 
a  soineichat  rapid  pulse,  reflex  muscular  contraction,  tenderness  on 
pressure,  pain  on  deep  inspiration,  and  manifests  slight  i-estlessness  without 
simultaneous  signs  of  a  severe  heBniorrhage,  then  the  case  is  so  suspicious 
of  an  injury  to  the  intestine  that  an  exploratory  incision  is  urgently 
indicated,  if  the  surrounding  circumitances  are  adapted  thereto,  as  in 
hospital. 

The  symptoms  just  described,  apparently  slight,  but  very  ex- 
pressive, may  persist  for  twelve  or  even  twenty-four  hours  without 
any  striking  changes.  But  then  the  scene  changes,  and  vomiting 
meteorism,  a  rapid  small  pulse,  show  us  that  peritonitis  has  set  in 
and  threatens  to  defy  all  therapeutic  measures. 


ABDOMINAL   INJURIES  247 

Xo  skill  is  required  to  recognize  a  rupture  of  the  intestine  in  this 
stage,  but  it  is  then  of  no  use,  and  only  gives  the  medical  attendant 
the  satisfaction  of  not  allowing  the  patient  to  die  without  a  diagnosis. 

The  foregoing  remarks  concerning  the  intestine  also  apply  to  the 
stoniacli,  which,  however,  is  much  more  rarel}^  injured  by  violence 
without  an  external  wound. 

(2)  THE  SPLEEN. 

If  an  increasing  area  of  dulness  in  the  left  half  of  the  abdomen  is 
accompanied  by  symptoms  of  continuous  haemorrhage,  without  signs 
of  an  injury  to  the  intestine,  Ave  must  think  of  a  ruptured  spleen, 
although  such  an  incident  as  an  isolated  injur}'  is  exceedingly  rare 
when  the  spleen  is  nonnal.  It  is  quite  different  when  the  spleen 
is  enlarged,  as  in  leukaemia,  malaria,  chronic  congestion,  and  cirrhosis 
of  the  liver.  In  these  cases  the  spleen  is  no  longer  protected  by 
the  ribs,  and  is  therefore  more  liable  to  injury.  The  following  case 
illustrates  this. 

An  alcoholic  female,  aged  50,  was  found  one  morning  dead  in 
bed  next  to  her  husband.  The  autopsy  showed  all  the  signs  of  severe 
alcoholism,  and  revealed  the  cause  of  death  in  the  rupture  of  a  spleen 
three  times  the  normal  size,  with  the  effusion  of  three  litres  of  blood  into 
the  abdominal  cavity.  Numerous  traces  of  bruises  on  the  body,  and 
the  evidence  of  a  night  scene  between  the  deceased  and  her  equally 
inebriated  husband,  elucidated  the  cause  of  the  injury  to  the  spleen. 

The  danger  to  which  an  enlarged  spleen  is  exposed  is  shown  by 
the  circumstance  that  a  malarial  spleen  has  ruptured  simply  owing  to 
palpation  through  the  abdominal  integuments. 

(3)   LIVER    AND    BILE-DUCTS. 

Injuries  to  the  liver  and  bile-ducts  are  much  more  frequent  than 
ruptures  of  the  spleen,  occurring  even  after  falls  from  a  height.  The 
danger  is  caused  both  by  the  risk  of  luvinorrhage  and  the  effusion  of 
bile  into  the  abdominal  cavity.  Haemorrhage  supervenes  very  quickly, 
and  shows  itself  by  dulness  over  the  right  side  of  the  abdomen,  in 
addition  to  the  usual  signs  of  loss  of  blood.  It  is  stated  that  this  dulness 
does  not  usually  descend  into  the  hypogastrium,  thus  contrasting  with 
splenic  haemorrhage.  If  at  the  same  time  the  liver  region  is  sensitive 
to  pressure,  and  there  are  radiating  pains  towards  the  right  shoulder, 
the  diagnosis  is  obvious.  But  it  is  not  always  as  easy  as  this  ;  some- 
times it  is  difficult  to  discover  whence  the  blood  is  issuing,  even  after 
the  abdomen  is  opened. 

It  is  even  more  difficult  to  recognize  a  flow  of  bile  into  the 
abdominal  cavity.  The  dulness  is  of  much  more  gradual  onset,  and 
its  position  will  var}'  according  to  the  direction  in  which  the  bile  is 


248       SURGICAL    DISEASES    OF   THE    ABDOMINAL    AXD    PELVIC    VISCERA 

poured  out.  It  may  flow  behind  the  stomach  into  the  lesser  omental 
sac,  or  into  the  lateral  and  inferior  portions  of  the  abdomen,  or  it 
may  be  limited,  by  rapidly  formed  adhesions,  to  the  mid-abdominal 
region.  If  a  diagnosis  of  injury  to  the  bile  ducts  is  based  on  an 
existing  and  gradually  increasing  fluid  effusion  into  the  abdominal 
cavity,  without  signs  of  acute  peritonitis  or  of  anaemia,  a  careful 
consideration  of  all  the  clinical  symptoms  will  often  indicate  the 
approximate  position  of  the  injury.  An  example  will  save  the 
necessity  of  any  long  disquisition. 

A  nine  year  old  lad  was  caught  under  the  wheel  of  a  cart.  After 
the  subsidence  of  the  first  severe  symptoms,  a  complete  dulness  of 
the  whole  upper  abdominal  region  supervened,  with  subsequent 
bilious  vomiting,  partial  but  not  complete  absence  of  colouration  from 
the  stools,  and  slight  jaundice.  The  gradual  onset  of  epigastric  dulness 
without  anaemia  pointed  to  an  effusion  of  bile,  and  the  jaundice 
showed  that  the  bile  was  absorbed  into  the  circulation.  But  as  there 
was  vomiting  of  bile  and  as  the  faeces  retained  some  biliary  colouring 
matter  it  was  obvious  that  the  bile  duct  was  not  torn.  But  the 
possibility  of  an  injury  to  the  gall-bladder  or  to  a  branch  of  the 
hepatic  duct  remained.  The  operation  showed  that  the  bile  had 
collected  in  the  lesser  omental  sac,  pushing  the  stomach  forward. 
This,  of  course,  excluded  an  injury  to  the  gall-bladder,  so  the  lesion 
could  only  be  a  rent  of  a  branch  of  the  hepatic  duct,  with  rapidly 
forming  fibrous  adhesions  around  the  foramen  of  Winslow. 

This  observation  confirms  the  general  experience  that  the  flow  of 
liealthy  bile  into  the  abdominal  cavity  is  comparatively  well  tolerated. 
A  fibrinous  peritonitis  usually  develops  around  the  effusion  of  bile, 
which  shuts  it  off  from  the  rest  of  the  abdominal  cavity,  and  if  not 
subjected  to  anything  but  very  slight  disturbance,  leads  to  spontaneous 
recovery.  But  if  the  effusion  of  bile  is  considerable,  and  if  instead 
of  reaching  the  intestine  it  becomes  absorbed  by  the  peritoneum,  the 
patient  finally  succumbs  to  cholaemia. 

It  is  quite  diff'erent  when  an  infected  ulcerated  gall-bladder  bursts 
in  the  course  of  cholecystitis  or  becomes  perforated  by  a  stone.  A 
fatal  general  peritonitis  generally  supervenes  in  a  very  short  time. 


(4)    THE    KIDNEYS. 

Despite  the  comparatively  protected  situation  of  the  kidneys,  they 
are  often  involved  in  injuries  which  produce  no  external  wound, 
especially  after  a  fall  from  a  height  or  after  being  run  over.  Pain  on 
pressure  over  the  renal  region,  and  blood  in  tJie  urine  confirm  the 
diagnosis,  at  any  rate  where  it  is  possible  to  exclude  injury  to  the 
lower  urinary  tract,  that  is  to  say,  when  there  is  no  injury  to  the  pelvis 
or  perineum  and  micturition  presents  no  difficulty.  Sometimes  the 
pain  on  pressure  over   the   injured    kidney  is   not  very   great  ;    but, 


ABDOMINAL    INJURIES  249 

on  the  other  hand,  the  reftcx  spasm  of  the  liiuibar  muscles  on  the 
injured  side  is  very  striking.  Unilateral  renal  colic  is  very  significant 
(obstruction  of  the  ureter  by  a  clot). 

Hcvmorrliage  is  the  principal  danger  in  renal  injuries.  The  extent 
of  an  extra-peritoneal  injury,  at  any  rate,  can  be  estimated  by  feeling  a 
swelling  over  the  renal  region  by  means  of  palpation  from  before  and 
behind,  noting  its  increase  and  also  the  onset  of  extending  dulness  in 
the  front.  The  most  reliable  conclusions  are  iiowever  to  be  drawn  from 
the  signs  of  an  increasing  anaemia,  which  we  must  not  confuse  with 
the  initial  signs  of  shock.  If  the  swelling  and  dulness  increase  in  the 
course  of  the  following  day,  without  corresponding  signs  of  anaemia, 
we  must  assume  that  urine  as  well  as  blood  is  being  effused,  and  this 
must  be  regarded  as  an  urgent  indication  for  interference.  But  some- 
times anaemia  may  occur  without  any  corresponding  palpable  change 
in  the  renal  region.  We  must  not,  in  such  a  case,  assume  that  the 
blood  is  retained  in  the  renal  pelvis  or  retro-peritoneal  tissue,  but 
rather  that  it  is  flowing  freely  into  the  abdominal  cavity,  that  is  to  say 
that  the  peritoneal  covering  of  the  kidney  is  torn  through.  These 
intra-peritoneal  injuries  of  the  kidney  are  especially  prevalent  among 
children,  because  their  kidneys  are  not  so  closely  enveloped  in  peri- 
renal fat  as  those  of  adults. 

One  may  feel  inclined  to  differentiate  between  extra  and  intra- 
peritoneal injury  of  the  kidney  on  the  basis  of  the  presence  or  absence 
of  the  gastric  and  intestinal  symptoms,  i.e.,  vomiting  and  meteorism. 
But  caution  is  necessary ;  because  gastric  disturbances  are  sometimes 
noted  in  extra-peritoneal  injuries  of  the  kidney.  This  may  be  due  to 
reflex  causes,  but  it  is  also  known  that  the  effused  blood  may  extend 
widely  in  the  retro-peritoneal  tissue  and  produce  functional  disturbance 
of  the  large  intestine,  with  all  the  symptoms  of  obstruction.  On  the 
other  hand,  vomiting  and  meteorism,  as  a  sign  of  peritoneal  irritation, 
are  not  indispensable  accompaniments  of  an  intra-peritoneal  rupture 
of  the  kidney.  Indeed  a  certain  amount  of  blood  and  even  of  urine 
is  well  borne  by  the  peritoneum.  The  formation  of  fibrinous 
adhesions,  as  shown  by  experiments  on  animals,  acts  as  a  defence 
against  a  persistent  inflow  of  urine,  a  circumstance  which  justifies 
waiting,  as  long  as  symptoms  are  not  on  the  increase. 

There  remain  therefore  two  definite  evidences  of  intra-peritoneal 
injury  of  the  kidney,  viz.  (i)  the  absence  of  definite  swelling  in  the 
renal  region,  with  (2)  the  simultaneous  presence  of  a  fluid  effusion 
free  in  the  abdominal  cavity,  arising  from  the  neighbourhood  of  the 
affected  loin.  But  not  even  this  absolutely  assures  our  diagnosis, 
because  we  must  be  able  to  prove  that  the  fluid  effusion  does  not 
originate  from  an  injury  to  some  other  abdominal  organ.  For 
instance,  an  extra-peritoneal  contusion  of  the  kidney  may  occur 
together  with  a  rent  in  the  liver  or  spleen.  But  in  these  cases  our 
diagnosis  cannot  get  beyond  the  range  of  probability. 

Even    if  the  first  few  critical  days  after  an   injury  to  the  kidney 


250       SURGICAL   DISEASES   OF   THE   ABDOMINAL   AND    PELVIC   VISCERA 

have  passed,  the  onset  of  local  inflammatory  signs  and  an  aggravation 
of  the  general  condition  after  an  initial  improvement  may,  at  this  later 
stage,  indicate  the  necessity  for  immediate  laparotomy.  Tissues  in- 
filtrated by  urine  are  especially  liable  to  infection,  and  even  if  sepsis 
of  the  urinary  tract  by  catheterism  has  been  avoided,  bacteria  may 
gain  access  from  the  blood  stream  or  from  the  neighbouring  intestine. 


(5)  THE    BLADDER. 

Rupture  of  the  bladder  only  occurs  when  the  viscus  is  full,  and 
the  accideiit  is  especially  liable  to  happen  to  an  intoxicated  person, 
because  he  tolerates  an  abnormally  full  bladder  with  equanimity, 
owing  to  his  state  of  alcoholic  anresthesia,  and  because  after  a  bout 
of  wine  and  beer,  at  any  rate,  the  bladder  possesses  the  fulness 
necessary  to  permit  of  the  injury. 

The  following  is  an  illustrative  case  :  An  alcoholic  had  reached 
the  stage  when  he  began  to  assault  one  of  his  comrades.  He  was 
therefore  ejected,  but  not  in  a  very  gentle  manner.  Very  shortly 
afterwards  he  died,  and  his  friends  were  charged  with  causing  his 
death  from  a  ruptured  bladder. 

The  clinical  picture  varies  according  to  the  site  of  the  rupture, 
viz.,  within  the  abdominal  cavity — inim-pcriioncal  rnpiurc,  or  into 
the  peri-vesical  cellular  tissue — exira-pi'vitoneal  ntpfurc. 

Let  us  imagine  that  a  patient  is  brought  to  us  on  account  of  a 
severe  abdominal  contusion.  He  complains  of  persistent  strangury, 
but  cannot  micturate.  Our  tirst  thought  is  of  a  urethral  injury  with 
obstruction  of  the  passage.  But  no  blood  flows  from  the  urethra,  and 
the  bladder  is  not  distended  above  the  symphysis  pubis.  We  percuss 
the  abdomen  immediately,  but  elicit  nothing  therefrom;  but  while  we 
are  examining  the  patient,  he  succeeds  in  passing  a  few  drops  of 
blood-stained  urine.  These  few  symptoms  suffice  for  the  diagnosis 
of  a  recent  iutra-pcyitoneal  riipiun'  of  tlie  bladder.  We  introduce  an 
ordinary  metal  catheter,  with  rigid  aseptic  precautions.  It  enters 
quite  easilv,  but  only  a  few  drops  of  bloody  urine  escape — although 
the  patient  assures  us  that  he  has  not  micturated  for  several  hours. 
On  moving  the  catheter  about,  we  miss  the  sensation  which  we  obtain 
when  it  is  in  a  full  bladder.  The  differential  diagnosis  lies  between 
one  of  two  things  only — (i)  refle.x:  anuria  following  trauma,  or  (2) 
intra-peritoneal  rupture  of  the  bladder.  The  strangury  and  the 
presence  of  blood  in  the  scanty  urine  are,  however,  decisive,  for  the 
latter.  If  the  patient  is  seen  for  the  first  time,  a  few  hours  or  a  day 
after  the  injurv,  an  additional  sign  is  present  on  percussion — viz.,  a 
fluid  effusion  in  the  lower  abdominal  region,  which,  however,  does 
not  present  the  convex  half-moon  shape  at  the  superior  border,  which 
is  found  in  a  free  intra-peritoneal  efiusion.     The  catheter  enters  the 


ABDOMINAL    INJURIES  251 

empty  contracted  bladder,  but  after  moving  it  about  therein,  we  may 
suddenly  find  that  it  becomes  quite  free,  and  a  large  amount  of  fluid 
escapes,  which,  on  chemical  examination,  is  shown  to  be  highly 
albuminous.  This  means  that  the  catheter  has  gone  through  the 
rent  in  the  bladder  into  the  abdominal  cavity,  and  has  drawn  off 
the  collection  of  urine,  mixed  up  with  albuminous  exudation.  The 
dulness  which  was  present  immediately  before  the  catheter  was 
passed  has  now  vanished.  If  the  patient  is  seen  in  a  still  later  stage, 
there  will  be  found  some  slight  peritoneal  irritabilitv  with  increasing 
effusion  of  fluid  in  the  abdominal  cavity.  If  attempts  have  been  made 
to  pass  a  catheter  there  is  every  prospect  that  this  peritoneal  irritability 
will  rapidly  become  a  definite  peritonitis.  We  should,  however,  avoid 
this  result  by  sewing  up  the  bladder  before  any  large  collection  of 
urine  takes  place  within  the  peritoneum,  or  before  uraemic  or  septic 
symptoms  arise. 

Extra-peritoneal  rupture  is  quite  different.  The  patient  complains 
principally  of  strangury,  but  he  passes  much  more  urine  than  in  cases 
of  intra-peritoneal  rupture,  and  the  catheter  shows  that  the  bladder 
is  not  completely  empty.  The  fact  that  there  is  an  injury  to  the 
bladder  is  indicated  by  the  presence  of  strangury,  while  the  urethral 
canal  is  quite  permeable,  and  by  the  presence  of  blood  in  the  urine 
without  symptoms  pointing  to  the  kidneys  or  urethra.  It  is  just  in 
this  circumstance  that  careful  attention  will  demonstrate  a  symptom 
concerning  which  Dittrich  stated  :  "  //  air  enters  the  bladder  hv  means 
of  the  catheter,  ice  shall  detect  a  limited  area  ivith  a  metallic  note 
immediately  over  the  symphysis." 

The  symptoms  hitherto  mentioned  are  apparentlv  mild,  but  they 
are  rapidly  complicated  by  the  onset  of  infiltration  of  urine  into  the 
pelvic  cellular  tissue,  which  causes  dulness  over  the  symphysis.  This 
may  be  followed  by  infiltration  and  phlegmonous  swelling  of  the  lower 
abdominal  region,  and  even  by  signs  of  uraemia.  Signs  of  peritoneal 
irritation  may  supervene,  but  these  play  quite  a  subordinate  part. 

Though  typical  cases  of  both  forms  of  injury  are  easilv  distin- 
guished, the  diagnosis  may  be  very  difficult  between  an  intra-peritoneal 
rnptnre  of  slight  extent  and  an  extra-peritoneal  injnry  of  very  extensive 
character.  In  the  former  case  errors  are  caused  by  the  fact  that  the 
bladder  always  contains  some  urine,  and  in  the  latter  case  because 
a  peritonitis  may  be  associated  with  the  manifestations  of  extra- 
peritoneal rupture.  The  main  thing,  however,  is  to  recognize  the 
fact  there  is  a  rupture  of  the  bladder. 

B.— INJURIES  T(3   THE   ABDOMEN    WITH  OPEN  WOUNDS. 

Open    injuries    are    generally    caused    by    stabs,    incisions,    or    by 
bullets.     Diagnosis  is  facilitated   because  the  position  and  direction 
of  the  injurv  to  the  soft  parts  give  some  definite  information  about  the 
17 


252       SURGICAL   DISEASES   OF   THE   ABDOMINAL   AND    PELVIC   VISCERA 

possibility  or  probability  of  injury  to  one  or  other  abdominal  organ. 
The  following  case  shows  that  one  must  take  into  consideration  the 
course  of  origin  of  the  injury  in  order  to  decide  upon  its  direction. 

A  young  man  was  hit  in  the  gluteal  region  by  a  Flobert  bullet, 
which  came  from  a  weapon  carelessly  placed  on  the  floor  behind  him. 
He  complained  at  once  of  abdominal  pain,  which  his  friends  attributed 
to  something  he  had  eaten — a  quite  probable  cause,  as  the  accident 
happened  on  a  public  holiday.  It  was  not  thought  at  first  that  a  bullet 
in  the  gluteal  region  could  cause  abdominal  pain.  Thirty  hours  later 
he  was  brought  to  the  hospital  with  symptoms  of  acute  peritonitis. 
The  wound  of  entry  was  found  above  the  left  gluteal  fold,  but  no 
wound  of  exit  could  be  seen.  The  bullet  had  struck  posteriorly  and 
interiorly,  and  must  have  gone  through  the  left  great  sciatic  foramen 
to  reach  the  abdominal  cavity.  As  a  matter  of  fact  the  X-rays 
revealed  the  bullet  in  the  right  lower  abdominal  region,  and  the 
operation  showed  that  there  was  a  double  perforation  in  the  last 
coil  of  the  small  intestine. 

(I)  GUNSHOT   WOUNDS. 

Gunshot  wounds  of  the  stomach  and  intestine  caused  by  the 
ordinary  small  firearms  differ  from  subcutaneous  lacerations  by  the 
smallness  of  their  extent.  In  the  case  of  bullets  of  very  fine  calibre, 
the  opening  is  so  small  that  it  is  very  difficult  to  discover  it  even  at 
the  operation.  This  also  applies,  as  recent  wars  have  shown,  to  the 
bullets  of  modern  military  firearms,  especially  to  the  conical  bullets, 
which  cause  little  deformity,  except  those  which  strike  diagonally. 
But  on  the  other  hand,  several  loops  of  intestine  are  often  shot 
through  at  the  same  time. 

The  symptoms  of  gastric  or  intestinal  injuries  are  naturally  the 
same  as  those  caused  by  violence  without  an  external  wound.  But 
the  symptoms  may  be  so  very  slight  when  the  diameter  of 
the  intestinal  wound  is  small,  and  the  bowel  is  empty,  that  spon- 
taneous healing  is  much  more  likely  to  take  place  than  in  the 
case  of  subcutaneous  lacerations.  Advantage  is  taken  in  war  of 
this  favourable  outlook,  where  the  impossibility  of  opening  the 
abdomen  at  the  right  moment  compels  us  to  dispense  with  this 
procedure.  It  is  quite  different  in  civil  practice,  when,  as  a  rule, 
timely  surgical  assistance  is  available  for  the  injured.  We  must 
not,  therefore,  wait  and  see  what  the  man's  luck  is  going  to  be, 
but  must  give  him  the  best  opportunity  of  recovering  by  means 
of  an  immediate  laparotomy.  Every  ahdouiiiuil  gitnsJwt  wound  ivhich 
by  its  direction  may  involve  the  stoinadi  or  intestine  is  so  suspicions 
of  having  caused  injury  to  the  intestinal  canal  if  the  projectile  can- 
not  he  found  in  the  abdominal  integunwnts,  that  it  is  absolutely 
urgent  to  bring  the  patient  to  the  hospital  at  once. 


ABDOMINAL   INJURIES 


253 


We  have  just  said  "if  the  projectile  cannot  be  found  in  the 
abdominal  integuments."  This  is,  however,  not  an  instruction  to 
undertake  a  search  for  it,  on  the  spot.  Formerly  the  surgeon  used 
to  take  a  probe  out  of  his  pocket-case,  insert  into  the  wound,  and 
if  it  reached  any  depth  would  exclaim  "  The  case  is  hopeless."  Of 
course  it  is  quite  clear  that  the  probe  can  often  inform  us  whether 
the  injury  has  perforated,  but  it  is  equally  clear  that  the  procedure 
may  arouse  a  fresh  haemorrhage,  tear  through  protective  adhesions, 
and  infect  a  wound  which  has  hitherto  remained  aseptic.  It  would 
be  a  safer  plan  to  lay  the  gunshot  track  freely  open,  after  thoroughly 
cleansing  it,  in  order  to  see  whether  the  bullet  still  remains  therein 
or  has  gone  through  the  peritoneum.  But  this  procedure  is  only 
permissible  when  everything  is  in  readiness  to  undertake  a  regular 
laparotomy  and  suture  the  stomach  or  intestine.  Otherwise,  w^e 
should  leave  our  probe  in  the  pocket-case,  with  the  other  instru- 
ments, apply  a  first  aid  dressing  and  send  the  patient  to  hospital 
forthwith.  I  have  never  seen  projectiles  discharged  at  close  quarters 
lodge  in  the  abdominal  integuments.  This  could  only  occur  with 
a  defective  charge,  or  when  the  bullet  has  been  stopped  by  pieces  of 
clothing.  To  enlarge  the  wound  of  entry  in  a  hurry  simplv  affords 
opportunity  for  infection  before  laparotomy  can  be  undertaken,  and 
deprives  the  surgeon  of  the  important  indication  which  the  direction 
of  the  track  gives  him  in  his  search  for  the  injured  intestine.  We 
should  limit  our  activity  to  a  careful  estimate  of  the  state  of  affairs — 
the  distance  and  direction  of  the  bullet — and  leave  the  wound  alone, 
despite  the  urgent  demands  of  the  patient  and  his  friends  for  the 
"  instant  removal  of  the  bullet." 

Gunshot  wounds  of  the  liver,  kidneys  and  bladder  are  diagnosed 
on  the  same  principles  as  injuries  of  these  organs  without  an  external 
wound. 

(2)  STABS  AND  INCISED  WOUNDS. 

Slabs  and  incised  wounds  which  penetrate  the  abdominal  wall 
are  so  suspicious  of  intestinal  injury  that  it  is  our  duty  to  make 
the  same  search,  as  in  the  case  of  gunshot  wounds.  How  do  we 
ascertain  whether  a  gunshot  wound  of  the  abdominal  wall  has 
perforated  ?  The  rules  laid  clown  in  this  regard  apply  equallv  to 
punctured  wounds,  i.e.,  ii  "  search  "  may  only  be  instituted  if  it  can 
be  immediately  followed  by  a  laparotomy.  In  all  other  circum- 
stances the  indications  are — first  aid  dressing,  careful  history  and 
removal  to  hospital. 

If  thei"e  be  no  protrusion  of  bowel  in  ijicised  ivounds,  we  should, 
when  circumstances  permit,  separate  the  wound  with  clean  hands, 
and  this  will  often  show  whether  it  has  penetrated  to  the  abdominal 


254       SURGICAL   DISEASES    OF   THE    ABDOMINAL    AND    PELVIC    VISCERA 

cavity.  In  cases  of  extensive  incised  wounds,  and  of  the  notorious 
laceration  inflicted  by  the  horns  of  bulls,  the  intestines  are  frequently 
protruding  when  the  patient  is  brought  for  treatment.  In  such 
circumstances  no  attempt  must  be  made  to  replace  the  bowel  ;  a  large 
first  aid  dressing  must  be  provided,  and  the  injured  at  once  sent 
into  hospital,  after  having  been  given  opium  as  an  intestinal  sedative. 

It  is  not  always  easy  to  discover  the  perforated  coil,  even  at  the 
operation.  For  example  :  A  fat  man  was  stabbed  in  the  left  lumbar 
region  with  a  slaughtering  knife.  No  symptoms  of  internal  haemor- 
rhage, no  signs  of  intestinal  injury,  and  no  blood  in  the  urine.  The 
position  of  the  wound  accorded  with  an  injury  to  kidney  or  spleen  ; 
the  length  of  the  knife  was  sufficient  to  have  wounded  the  bowel. 
On  opening  up  the  wound,  an  injury  to  the  lower  pole  of  the  kidney 
was  discovered,  and  laparotomy  revealed  the  expected  complete  rent 
of  two-thirds  of  the  circumference  of  the  descending  colon  at  the 
renal  flexure,  although  this  is  a  rare  event. 

Stabs  of  the  large  intestine  are,  as  a  rule,  much  rarer  than   knife 
wounds  of  the  small  intestine. 


CHAPTER  XXXVI. 

ACUTE  INFLAMMATION  WITHIN  THE  ABDOMINAL 

CAVITY. 

Before  attempting  to  discover  the  origin  of  any  inflammatory 
disease  within  the  abdomen,  we  first  make  sure  that  an  inflammatory 
process  really  exists.     This  is,  however,  not  always  easy. 

Let  us  consider  two  tvpical  cases.  A  patient  suddenly  begins  to 
complain  of  abdominal  pains  and  to  vomit.  The  temperature  is 
slightly  raised,  the  pulse  is  accelerated,  the  breathing  is  shallow,  and 
almost  exclusively  thoracic  in  type  ;  the  abdomen  is  not  distended— 
it  is,  however,  tender  on  light  percussion,  and  responds  thereto  by 
nuiscular  contraction.  Pressure  over  the  huubar  regions  is  painful 
either  on  one  or  on  both  sides.  Neither  flatus  nor  stools  pass ;  but 
there  is  no  visible  peristalsis.  The  patient  complains  of  a  constant, 
dull  pain,  which  varies  in  severity,  but  does  not  cease  completely. 
There  is  no  doubt  at  all  that  peritonitis  is  beginning  in  this  case. 
Let  us  compare  this  with  the  other  case.  The  illness  also  begins  with 
abdominal  pains  and  vomiting ;  but  the  pulse  is  quiet  and  full,  except 
at    the     actual    time    of    nausea   and    vomiting;    the   temperature  is 


ACUTE    IXFJ.A^niATIOX    WITHIX    THE    ABDO:\nXAL   CAVITY  2:^5 

normal,  the  breathing  is  not  accelerated,  nor  particularly  shallow. 
The  abdomen  is  not  distended,  or  only  slightly  so  ;  during  the  periods 
of  repose  it  is  not  tender  either  to  pressure  or  percussion,  and  the 
abdominal  muscles  do  not  markedly  contract  on  palpation.  Neither 
flatus  nor  stools  pass.  An  attack  of  pain  occurs  from  time  to  time, 
during  which  peristalsis  can  be  seen  if  the  abdominal  wall  is  thin. 
The  attack  hardly  lasts  a  minute  ;  when  it  is  over,  the  patient  feels 
well  until  the  next  attack  warns  one  that  some  severe  disturbance  is 
in  progress.  Evidently  this  is  a  case  of  inicstinal  obstritcfioii.  The 
differential  diagnosis  between  peritonitis  and  intestinal  obstruction 
is  usually  quite  easy  in  the  early  stage.  But  this  early  stage  must  be 
most  careful!}^  watched,  and  if  we  are  called  too  late  for  this  we  must 
obtain  its  histoiy  as  accurately  as  possible,  because  as  the  illness 
advances  the  differentiation  becomes  more  difBcult.  In  peritonitis 
the  abdomen  distends  gradually,  the  temperature  is  not  alwavs  raised, 
but  often  becomes  sub-normal,  and  symptoms  of  functional  or 
mechanical  obstruction  are  frequently  added  to  those  of  simple 
inflammation.  In  obstruction,  on  the  other  hand,  the  pulse  becomes 
small  and  rapid,  as  the  case  progresses,  the  temperature  mav  rise,  and 
the  abdomen  remains  tensely  tympanitic  even  in  the  intervals  which 
are  free  from  pain.  The  pain  eventually  becomes  persistent,  and  the 
mechanical  obstruction  is  supplemented  bv  intestinal  paralvsis,  or 
even  bv  peritonitis. 

If  the  initial  symptoms  lead  us  to  the  conclusion  that  some 
inflammatory  irritation  of  the  peritoneum  exists,  we  must  not  be 
content  with  the  vague  diagnosis  of  "  peritonitis,"  but  must  endeavour 
to  trace  its  sources  as  quickly  as  possible.  Careful  investigation  and 
observation  at  the  beginning  are  of  the  greatest  importance  for  this 
purpose,  for  once  the  peritonitis  has  become  generalized  we  are  no 
more  able  to  discover  its  origin  than  we  can  detect  the  origin  of  a  fire 
when  the  whole  house  is  ablaze.  In  this  stage  it  is  generally  too  late 
to  successfully  overcome  the  inflammation. 

The  method  by  which  inflammation  of  a  limited  area  spreads  over 
the  whole  abdomen  follows  various  tvpes  : — 

(i)  In  the  first  group,  we  are  confronted  within  the  first  few  hours 
by  a  diffuse,  and  generally  a  simple  toxic  irritation  of  the  peritoneum, 
presenting  all  the  symptoms  of  a  mild  generalized  peritonitis  ;  but 
there  may  be  no  specially  sensitive  spot  to  indicate  the  origin  of  the 
mischief.  In  fact,  in  these  cases,  the  patient  is  unable  to  say  where 
the  pain  started.  On  opening  the  abdomen  a  serous,  or  even  a  some- 
what turbid  exudation  containing  leucoytes,  but  always  odourless,  is 
found ;  but  no  organisms  can  be  cultivated  therefrom.  In  a  few 
hours,  or  at  any  rate  after  a  few  days'  interval,  the  general  symptoms 
abate,  the  spontaneous  pain  as  well  as  the  pain  on  pressure  limit 
themselves  more  and  more  to  an  area  which  corresponds  to  the 
original  seat  of  the  mischief.     Indeed  an  abscess  is  forming,  and  cure 


256       SURGICAL   DISEASES   OF   THE   ABDOMINAL   AXD   PELVIC   VISCERA 

may  take  place  either  by  its  absorption   or  by  perforation  into  the 
bowel  (fig.  143,  a — //). 

(2)  In  the  second  group  the  initial  symptoms  resemble  the  above^ 
but  the  reaction  of  the  peritoneum  is  more  acute.  The  exudation 
soon  contains  bacteria — usually  from  the  second  day  in  cases  of 
appendicitis — and  often  has  an  offensive  odour  if  the  infection 
has  come  from  the  intestine.  Subsequently  the  peritonitis  diminishes 
in  some  places,  in  others  fibrinous  investments  form,  whereas  at  the 
periphery  of  the  abdomen  there  is  a  tendency  to  the  development  of 
encapsuled  abscesses,  entirely  independent  of  the  original  area  of  the 
disease  (fig.  143,  k),  the  so-called  "residual  abscesses"  (Restabszessen). 
We  agree  with  Sprengel,  &c.,  in  interpreting  in  this  sense,  the 
"progressive  fibrino-purulent  peritonitis"  of  Mikulicz  and  Burckhardt, 

(3)  In  other  cases,  after  the  general  peritonitis  subsides  and  the 
inflammation  has  become  localized,  a  fresh  and  more  severe  attack  of 
peritonitis  may  supervene,  which  signifies  that  either  the  primary  or 
a  residual  abscess  has  burst  into  the  peritoneal  cavity. 

(4)  In  the  severest  cases  the  symptoms  are  generalized  from  the 
beginning,  and  remain  so  until  death.  The  sero- purulent  peritonitis 
merges  into  the  diffuse  purulent  form,  and  the  clinical  symptoms 
depend  more  upon  the  virulence  of  the  micro-organisms  than  upon 
the  anatomical  conditions. 

Some  additional  general  remarks  are  required  to  introduce  the 
discussion  of  the  individual  forms  of  peritonitis. 

The  previous  history  is  often  very  valuable.  Suft'erers  from 
appendix  trouble  and  gall  stones,  who  have  already  experienced 
attacks,  recognize  the  seat  of  their  malady.  In  females,  a  reliable 
history  is  indispensable,  but  is  often  difficult  to  obtain.  For  instance, 
in  criminal  abortion,  as  well  as  in  spontaneous  abortion  which  the 
patient  is  reluctant  to  confess,  she  often  endeavours  to  make  her 
friends  and  medical  attendant  adopt  the  view  that  the  case  is 
appendicitis. 

If  some  general  disease  has  preceded  the  peritonitis  we  should 
think  of  typhoid  perforation.  These  perforations  are  more  frequently 
overlooked  than  one  imagines,  because  the  symptoms  are  partially 
masked  by  the  underlying  disease.  A  few  years  ago  a  well-known 
surgeon  died  from  an  undiagnosed  perforation  occurring  in  the  course 
of  an  undiagnosed  typhoid  fever,  although  he  was  surrounded  by 
physicians  and  surgeons — which  ought  to  be  very  consoling  to  the 
general  practitioner. 

The  (igc  and  sex  of  the  patient  must  be  taken  into  consideration. 
In  the  male  sex,  up  to  the  age  of  20,  the  vermiform  appendix  is  so 
frequently  at  fault,  that  this  ought  to  be  our  first  thought,  in  every 
case  of  peritonitis,  even  if  it  has  not  started  on  the  right  side.  After 
the  age  of  20  such  comparatively  rare  causes  as  perforated  gastric  or 
duodenal  ulcers  may  suggest  themselves,  or  exceptionally,  perforation 
of  a  tubercular  ulcer  of  the  small  intestine.  From  the  age  of  40  or  50, 
or   even   earlier,  we   sliould   also   think   of    the    gall-bladder.      Indeed^ 


ACUTE    INFLAMMATIOX    WITHIN    THE    ABDOMINAL    CAVITY         257 

with  the  advance  of  age,  the  probabihty  of  the  gall-bladder  being 
responsible,  and  not  the  appendix,  increases.  Intestinal  perforation 
due  to  cancer  falls  within  the  same  age  period.  I  have  only  once 
seen  a  case  of  calculous  cholecystitis  imitate  appendicitis  before  the 
age  of  20,  and  this  was  in  a  girl  aged  18. 

In  the  fcinalc  sex,  among  girls,  we  have  to  think,  in  addition  to 
perityphilitis,  of  pneumococcal  peritonitis — a  rarity  among  boys. 
This  often  develops  quite  independently  of  the  vermiform  appendix, 
and  we  shall  deal  with  it  again  later  on.  After  puberty,  once  the 
hymen  is  ruptured,  all  the  inflammatory  processes  which  may  start 
in  the  sexual  organs  must  be  taken  into  consideration.  An  intact 
hymen,  as  JMcRae  rightly  savs,  points  to  appendicitis  in  doubtful 
cases. 

We  begin  our  pJiysical  cxaui'uiation  with  2.  general  view  of  the  entire 
patient. 

Nothing  is  so  reassuring  as  a  face  in  repose.  Nothing  fills  us 
with  so  much  apprehension  as  the  restlessness  which  the  patient 
manifests  about  everything  ;  the  haste  with  which  he  persuades  us 
that  nothing  ails  him,  that  he  feels  well,  although  his  pulse  is  hardly 
perceptible.  Flushes  on  the  face  and  ears  indicate  that  he  is  within 
the  grasp  of  peritonitis,  and  cyanosis,  first  to  be  detected  on  the  finger 
nails,  signiBes  that  the  toxaemia  is  well  advanced.  Jaundice,  sometimes 
nothing  more  than  a  slight  pigmentation  of  the  sclerotics,  is  not  rare 
in  general  peritonitis,  and  it  is  of  bad  omen.  A  moist  tongue  is  a 
good  sign,  although  it  may  be  coated.  A  dry  tongue,  even  uncoated, 
shows  that  mischief  still  persists  somewhere,  that  the  system  has  not 
yet  mastered  the  infection.  We  conclude  from  rapid  shallow  breathing 
in  which  the  nostrils  participate  that  the  peritonitis  is  on  the  increase, 
or  when  the  face  is  generally  flushed  that  some  complication  exists  in 
the  lung.  Quiet,  painless  breathing  shows  that  the  inflammatory  area 
has  become  limited.  A  full  pulse,  slow  in  relation  to  the  temperature, 
IS  a  good  sign  ;  a  small  soft  pulse,  rapid  in  relation  to  the  temperature, 
is  of  bad  import ;  a  pulse  of  normal  amplitude,  but  soft  and  rather 
dicrotic,  indicates  an  inflammatorv  focus  in  the  abdomen,  which  has 
not  yet  been  overcome. 

The  age  and  sex  of  the  patient  must  be  taken  into  consideration 
when  estimating  the  pulse-rate.  Sometimes  a  peritonitis  may  be 
fully  developed,  especially  in  men,  and  the  pulse  does  not  exceed  90. 
On  the  other  hand,  in  children,  a  pulse-rate  of  120  to  140  is  not  of 
serious  significance.  If  the  pulse  persists  at  130  and  over,  in  adults, 
the  condition   is  very  grave. 

The  temperature  as  taken  in  the  axilla  is  of  but  little  value.  Often 
enough,  it  does  not  exceed  the  normal,  even  in  fatal  peritonitis.  But 
it  is  important,  v^dien  compared  with  the  rectal  temperature  ;  for  the 
greater  the  divergence,  the  worse  the  outlook. 


258       SURGICAL    DISEASES    OF   IHE    ABDOMINAL    AND    PELVIC    VISCERA 

We  now  proceed  to  the  examination  of  ilie  abdomen.  We  must 
first  empty  the  bladder  with  a  Nelaton  catheter :  even  if  the  patient 
has  micturated  in  our  presence.  Patients  with  abscesses  in  the  lower 
abdomen  do  not  completely  empty  the  bladder,  and  it  often  happens 
that  the  full  bladder  is  mistaken  for  an  effusion  "  because  the  patient 
has  only  just  micturated." 

We  seize  the  opportunity  of  using  the  catheter,  to  examine  the 
urine,  and  if  albumen  or  much  indican  be  present,  we  conclude  that 
the  illness  is  severe.  Bile  pigment  indicates  disease  of  the  bile  ducts, 
and  sugar  suggests  some  pancreatic  affection. 

In  estimating  meteorism,  we  must  remember  that  the  abdominal 
circumference  in  young  people  and  in  the  male  sex  is,  ceteris  paribus^ 
smaller  than  in  females.  In  percussing,  very  light  movements  are 
required  in  order  to  detect  a  superficial  thin  layer  of  effusion. 

Direct,  one-finger  percussion,  known  as  palpation-percussion,  is  a 
valuable  method,  in  patients  who  are  not  too  stout.  The  whole 
abdomen  is  percussed  lightly  with  the  middle  finger  applied  flat,  by 
which  device,  dulness  can  he  felt  as  well  as  it  can  be  heard.  It  is  best 
always  to  employ  both  methods  of  percussion  and  compare  the  results. 
The  presence  of  a  metallic  note  over  individual  loops  of  intestine 
is  of  special  significance.  It  is  an  important  sign  of  a  strangulation, 
a  kink,  or  of  local  peritonitis  ;  the  same  applies  to  circumscribed 
crepitations  always  heard  over  the  same  place,  or  to  the  peristaltic 
metallic  note  so  carefully  described  by  Wilms  and  Leuenberger. 
Palpation  must  be  very  cautious.  It  is  better  to  remain  uncertain  of 
the  precise  extent  of  an  abscess,  rather  than  to  break  down  protective 
adhesions  through  want  of  care.  The  more  carefully  one  proceeds 
the  more  reliable  will  be  the  result  of  the  examination.  If  the  per- 
cussion is  carefully  conducted  reflex  muscular  contraction  will  cause 
much  less  interference  and  liability  to  error,  than  when  a  rough 
method  is  adopted.  We  cannot  entirely  avoid  this  muscular  contrac- 
tion ;  its  presence  is  very  well  known,  but  is  not  sufficiently  appreciated 
as  an  aid  to  diagnosis. 

This  contraction,  or  "  defense  musculaire  "  which  we  have  already 
mentioned  in  connection  with  abdominal  injuries,  occurs  in  the 
muscles  which  cover  over  the  diseased  area  and  it  constitutes  the 
first  sign  of  inflammatory  irritation  of  the  parietal  serous  membrane. 
It  diminishes  with  the  course  of  the  disease,  or  limits  itself  to  those 
areas  which  the  inflammatory  process  has  involved,  in  its  spread. 
In  cases  wherein  the  whole  abdominal  cavity  is  inundated  by  infective 
material,  particularly  after  extensive  gastric  perforation,  the  entire 
abdominal  wall  becomes  firmly  contracted,  or  at  least  contracts  as 
soon  as  the  slightest  touch  impinges  upon  it.  In  perityphlitis,  the 
contraction  is  usually  limited  to  the  right  lower  abdominal  region, 
and  if  the  process  spreads  towards  the  loin  then  the  lumbar  muscles 
of  the  right  side  contract.  If  the  lumbar  muscles  of  the  left  side  also 
contract   on   pressure,   we   may  be  sure  that  the  peritoneal  irritation 


ACUTE    INFLAMMATION    WITHIN    THE    ABDOMINAL    CAVITY         259 

lias  spread  to  that  quarter.  This  is  the  more  pronounced,  the  more 
the  parietal  peritoneum  is  involved  in  the  inflammation,  and  it  may 
therefore  be  entirely  absent  when  the  inflamed  area  is  deeply  situated, 
e.g.,  in  meso-caeliac  or  pelvic  appendicitis.  The  respiratory  fixation 
of  the  muscles  in  the  vicinity  of  the  diseased  area  is  also  due  to  this 
reflex  contraction,  as  shown  by  Kuster.  It  is  noteworthy  that  this 
reflex  contraction  is  much  slighter  in  puerperal  cases  than  in  those 
infected  from  the  intestine. 

In  examining  for  sensitiveness  to  pressure,  we  must  not  be  misled 
by  expressions  of  pain  which  nervous  people  will  manifest,  just 
like  spoilt  children,  even  when  pressure  is  made  on  healthy  organs. 
If  the  peritoneum  is  really  inflamed,  pain  will  be  elicited  when  the 
hand  is  suddenly  removed  after  gentle  pressure. 

It  is  necessary  to  make  a  brief  observation  here,  regarding  the 
perception  of  pain  in  the  abdominal  organs.  Although  Harvey  and 
Haller  had  already  shown  that  the  viscera  do  not  respond  to  ordinary 
irritation,  by  pain,  nevertheless  the  site  of  morbid  pain  sensations 
at  any  rate,  was  localized  in  the  viscera  themselves,  until  a  few  years 
ago.  Lennander  opposed  this  view^,  as  a  result  of  his  careful  investiga- 
tions, and  he  sought  to  explain  all  sensations  of  pain  by  dragging 
or  friction  of  the  nerves  of  the  anterior  or  posterior  abdominal  wall, 
including  the  mesenteric  attachments.  Ross,  and  subsequently  Head, 
assumed  that  local  pain  sensibility  may  occur  in  the  abdominal  viscera 
themselves,  giving  rise,  reflexly,  to  sensations  of  pain  in  a  correspond- 
ing area  of  the  abdominal  wall.  Head  went  a  step  further  and 
endeavoured  to  show  by  numerous  investigations,  that  disease  of 
a  thoracic  or  abdominal  organ  produced  severe  localized-  hyper- 
sesthesia  in  a  very  definite  segmentary  area  of  skin  integument, 
corresponding  to  the  abdominal  organ.  If  we  adopt  this  theory, 
we  must  not  any  longer  attribute  local  hypersesthesia  to  pure  func- 
tional disturbance  (hysteria),  without  considering  the  possibility  of 
some  deep-seated  disease.  James  Mackenzie  has  made  numerous 
observations  which  have  led  him  to  certain  conclusions  of  no  small 
diagnostic  interest,  and  which  we  will  here  briefly  summarize.  Like 
Lennander,  he  assumes  that  stimuli  such  as  pinching,  pricking,  and 
burning  are  inadequate  to  excite  the  sensation  of  pain  in  the 
abdominal  organs  themselves.  Even  an  adequate  stimulus  like  con- 
traction does  not  suffice  to  excite  a  sensation  of  pain,  under  normal 
circumstances.  But  if  these  stimuli  exceed  a  certain  degree  they 
irritate,  in  the  sense  of  a  viscero-sensory  reflex,  sensory  fibres  in 
the  spinal  cord,  which  come  from  the  corresponding  area  of  the 
abdominal  integument,  and  they  also  irritate,  as  a  viscero-motor 
reflex,  motor  fibres  which  proceed  to  coiTcsponding  muscle  segments. 
Thus,  if  we  pinch  an  intestinal  segment,  we  excite  no  pain.  But 
if  the  intestine  contracts  in  an  unusually  marked  degree,  the  irritation 
reaches  the  spinal  cord  and  stimulates  therein  spinal  pain  fibres, 
causing  the  brain  to  appreciate  pain  in  the  corresponding  spinal 
segment.  This  pain  is  referred  to  the  corresponding  area  of 
abdominal  skin  and  not  to  the  abdominal  viscus,  from  which  the 
irritation  arises  (referred   pain).     The   muscles  of   the  corresponding 


26o       SURGICAL    DISEASES    OF   THE    ABDOMIXAL   AXD    PELVIC    VISCERA 

segment    may  be    simultaneously  irritated,  causing   reflex   abdominal 
contraction. 

Although  this  view  is  to  some  extent  hypothetical,  it  explains 
Lennander's  observations,  which  are  in  themselves  very  accurate, 
much  better  than  his  own  theory. 

Finally  we  should  make  a  rectal  or  a  vaginal  examination,  which 
will  clear  up  the  condition  of  the  female  genital  organs,  afford 
intormation  as  to  the  existence  of  a  peh/ic  abscess,  and  allow  us 
to  decide  whether  it  should  be  opened  from  above  or  below.  The 
more  deeply  it  is  situated  the  more  evident  it  will  be,  not  only  bv 
the  bulging  but  also  by  the  cedematous  swelling  of  the  mucous 
membrane — feeling  like  velvet — and  bv  the  profuse  discharge  of  jellv- 
like  mucus.     Tenesmus  is  rarely  absent. 

In  arriving  at  a  decision  in  cases  of  peritonitis,  we  must  bear  in 
mind  a  fact  which  is  often  forgotten  in  practice,  that  all  cases  do 
not  present  a  typical,  clinical  picture.  Sometimes  on  operating  we 
find  the  intestines  swimming  in  pus,  although  the  clinical  symptoms 
may  not  have  led  us  to  anticipate  any  severe  disease.  The  pulse 
remains  good,  the  reflex  muscular  contraction  is  slight.  There  is 
neither  vomiting  nor  intestinal  paralvsis,  and  the  patient  i-ecovers 
despite  the  gloomy  outlook.  There  are  two  reasons  for  these  ex- 
ceptional cases.  In  the  first  place  the  peritonitis  is  not  so  generalized 
as  it  appears  to  be.  The  convolutions  of  the  small  intestine,  although 
bathed  in  pus,  are  not  infected  between  the  individual  loops,  being 
protected  by  the  omentum  and  bv  fibrous  adhesions  (Lennander's 
peripheral  peritonitis).  The  second  reason  is  just  as  important,  if 
not  more  so  :  the  slight  virulence  of  the  pus  organisms.  For 
instance,  the  pneumococcus  is  comparatively  harmless  in  children, 
and  a  central  peritonitis  due  to  it  mav  run  an  excellent  course 
although  the  condition  found  at  operation  leads  us  to  think  that 
the  case  must  prove  fatal.  Other  micro-organisms  mav  also  be 
equally  innocuous,  in  exceptional  instances.  We  need  only  think 
of  cases  of  acute  peritoneal  sepsis  which  are  fatal  before  anatomical 
changes  have  had  time  to  form  in  the  serous  membrane,  to  realize 
that  the  prognosis  of  peritonitis  depends  more  upon  the  virulence 
of  the  micro-organisms  than  upon  the  extent  and  intensity  of  the 
anatomical  changes. 

In  concluding  these  general  observations  we  must  mention  that 
our  attention  must  not  be  devoted  to  the  abdomen  alone.  There  is 
often  a  recurrence  of  fever  in  the  course  of  peritonitis,  after  some 
improvement  has  begun.  The  tongue  becomes  dry  again.  Nothing 
is,  however,  to  be  felt  in  the  abdomen  ;  but  the  remarkably  rapid 
breathing,  the  diffuse  congestion  of  the  face,  and  the  dicrotic  pulse 
will  forthwith  suggest  some  lung  complication  to  the  experienced 
observer.  Careful  examination  will  reveal  either  a  pneumonia  or  a 
pleurisy,  or  both  together,  usually  as  a  metastatic  process,  but 
in  the  case  of  pleurisy  it  may  be  the  result  of  direct  extension 
through  the  diaphragm. 


ACUTE    IXFLAM.MATIOX    WITHIX    THE    ABDOMIXAL    CAVITY         261 

Attempts  have  been  made  for  a  number  of  years  to  base  indications 
for  diagnosis  and  prognosis  on  the  condition  of  the  white  corpuscles 
in  cases  of  inflammatory  disease — especially  of  the  abdominal  cavity. 

As  a  point  of  diagnosis  it  is  established  that  a  great  leucocytosis, 
independent  of  digestion,  probably  indicates  an  inflammatory  disease. 
On  the  other  hand,  a  normal  or  even  a  diminished  leucocyte  count  does 
not  by  any  means  exclude  an  infective  disease  (typhoid).  As  far  as 
prognosis  is  concerned  a  high  leucocvte  count  in  the  presence  of  severe 
general  symptoms  is  a  good  sign  ;  a  low  count  is  a  bad  sign. 

Endeavours  have  been  made  to  arrive  at  more  definite  indications 
from  a  differentia/  coiiiif  of  ill e  zvhite  cells  of  the  blood  and  from  special 
changes  in  the  neutrophil  polynuclear  leucocytes.  Schindler  takes  into 
consideration  the  number  of  myelocytes ;  Arneth  counts  the  nuclei, 
or  fragments  of  nuclei,  of  the  neutrophil  polynuclear  leucocytes, 
and  draws  conclusions  from  their  greater  or  lesser  fragmentation. 
Sondern  finds  an  aid  to  prognosis  in  the  proportion  of  the 
leucocytosis  in  general,  to  the  percentage  of  the  polymorpho-neu- 
trophil  leucocvtes.  All  these  various  methods  give  some  information 
concerning  the  defensive  activities  of  the  organism.  But  it  is  indis- 
pensable, in  the  case  of  them  all,  that  the  examinations  should  be 
made  at  regular  intervals,  just  like  the  taking  of  temperature.  This, 
however,  requires  adequate  laboratorv  equipment  and  a  certain 
amount  of  technical  experience,  in  addition  to  more  time  than  a  prac- 
titioner can  usually  devote  to  individual  patients,  and  therefore  these 
methods  must  be  practicallv  limited  to  hospitals  and  clinics.  The 
practitioner  does  not  possess  the  necessary  leucocyte  curve  at  the 
moment  he  is  called  to  the  patient  to  enable  him  to  arrive  at  a 
decision,  and  to  wait  for  the  preparation  of  one  may  frequently  delay 
surgical  intervention  until  it  is  too  late.  As  Kocher  once  said,  the 
main  thing  in  appendicitis  is  not  to  demonstrate  a  hyper-leucocytosis, 
but  to  prevent  its  onset  by  early  operation.  On  the  other  hand,  a 
leucocyte  curve  is  of  value  for  the  hospital  surgeon  in  deciding,  for 
instance,  whether  a  late  case  of  appendicitis  requires  operation,  or 
whether  a  second  operation  is  necessar\"  in  the  course  of  a  suppurative 
disease  of  the  abdominal  cavity. 

We  now  proceed  to  construct  a  diagnosis  from  the  conditions 
found  upon  physical  examination.  The  most  frequent  of  these 
conditions  may  be  classified  as  follows  : — 

(a)  Symptoms  of  pain  without  perceptible  changes. 

(b)  Symptoms  of  pain,  with  signs  of  general  peritoneal  irritation 
without  definite  localization. 

(t)   Peritoneal  irritation,  with  circumscribed  changes. 

/!.— ABDOMINAL  PAIN  WITHOUT  PERCEPTIBLE 

CHANGES. 

The  first  group  of  symptoms,  characterized  by  spontaneous  pain 
and  by  local  pain  on  pressure,  without  any  obvious  change,  is 
responsible   for  most  of   the  errors   of  diagnosis.     We    may   hesitate 


262       SURGICAL    DISEASES    OF    THE    ABDOMINAL    AND    PELVIC   VISCERA 

between  hysteria,  crises  of  tabes,  a  mild  attack  of  appendicitis,  an 
attack  of  mucous  colic,  renal  or  biliary  colic,  some  disease  of  the 
female  genitalia,  acute  intestinal  obstruction,  and  even  an  inflam- 
matory disease  of  the  thoracic  organs. 

Suspicion  of  some  hysterical  condition  will  be  aroused  by  any 
striking  contrast  between  the  complaints  made  and  the  actual  con- 
dition found.  Formerly,  hypersesthesia  of  the  skin  suggested  hysteria, 
but  as  we  know  now  that  disease  of  deeply  situated  organs  may  be 
recognized  by  superficial  hyperaesthesia,  we  must  be  cautious  in  the 
interpretation  of  this  sign.  Simultaneous  deep  and  superficial  hyper- 
algesia may  be  due  to  hysteria,  but  is  not  necessarily  so.  But 
"appendicitis"  is  certainly  hysterical  if  the  hyperaesthesia  is  exclusively 
confined  to  the  skin. 

We  must  examine  for  tabes  in  every  case,  wherein  the  other 
conditions  are  reconcilable  with  this  diagnosis. 

A  female,  aged  50,  became  ill  suddenly  one  night  with  severe 
abdominal  pain,  which  suggested  an  acute  gastric  or  intestinal 
perforation.  Although  physical  examination  proved  negative,  the 
question  of  laparotomy  was  contemplated,  but  the  history  made  one 
hesitate.  Her  husband  had  died  twenty  years  ago  from  paralysis,  she 
had  had  one  miscarriage,  and  a  swelling  on  the  skull  which  had  been 
cured  by  potassium  iodide.  Further  examination  show^ed  that  the 
pupil  reflex  was  lost,  and  that  the  knee  jerks  were  absent — the  only 
signs  of  tabes.  The  abdomen  was  not  opened.  Rectal  crises  occurred 
later  on,  in  confirmation  of  the  diagnosis. 

Attacks  of  mucous  colitis  are  often  mistaken  for  inflammatory 
diseases.  Muco-membranous  colitis,  with  its  ileo-coecal  pain,  tender- 
ness on  pressure  over  the  appendix  region,  and  its  transitory  pulse 
of  collapse  arid  vomiting  may  completely  resemble  an  attack  of 
appendicitis. 

We  merely  refer  to  the  matter  here,  but  will  discuss  it  more  fully 
in  connection  with  chronic  appendicitis.  Other  symptoms  of  pain 
in  the  large  intestine,  the  significance  of  which  is  often  difficult  to 
decide,  will  be  dealt  with  together  later  on. 

The  gums  should  always  be  examined  in  unexplained  colic,  lest 
a  case  of  lead  colic  be  missed. 

In  renal  colic  either  a  normal  or  enlarged  kidney,  sensitive  to 
pressure,  is  felt,  or,  at  any  rate,  pronounced  reflex  contraction  of  the 
lumbar  muscles  is  present.  The  pain  radiates  into  the  genital  organs 
and  even  to  the  thigh,  and  the  corresponding  testicle  may  be 
abnormally  sensitive  to  pressure. 

Gall-bladder  colic  is  distinguished  from  renal  colic  and  appen- 
dicular pain  by  the  situation  of  the  sensitive  area,  which  is  internal 
to  the  outer  border  of  the  rectus,  and  at  the  level  of,  or  above  the 
umbilicus.  They  may  easily  be  mistaken  for  duodenal  pain  ;  but 
gall-stones  usually  occur  in  females  and  duodenal  ulcers  in  males. 


ACUTE    INFLAMMATION    WITHIN    THE    ABDOMINAL   CAVITY         263 

Temporary  strangulation  of  a  hernia,  which  has  been  overlooked 
both  by  patient  and  doctor,  may  be  mistaken  for  a  mild  attack  of 
appendicitis,  quite  apart  from  appendicitis  in  a  hernial  sac. 

On  one  occasion  I  removed  the  appendix  of  a  middle-aged  woman 
on  account  of  the  history  of  appendicitis,  and  the  diagnosis  made 
by  the  medical  attendant  during  the  attacks.  But  the  attacks 
returned,  and  I  eventually  discovered  the  cause  in  a  right-sided 
crural  hernia,  which  could  hardly  be  detected  by  the  most  careful 
examination.  The  mistake  could  have  been  avoided  by  accurate 
observation  of  the  temperature  during  the  attacks.  There  is  invariably 
some  rise  of  temperature  in  appendicitis,  but  if  it  is  slight  it  may  have 
passed  away  before  the  arrival  of  the  doctor.  If  there  are  no  physical 
signs  to  account  for  a  high  temperature  taken  bv  the  patient  himself, 
we  should  then  take  it  ourselves,  so  as  to  exclude  any  artificial 
pyrexia  due  to  friction  against  the  theruiometer.  In  one  hysterical 
case  the  thermometer  was  so  manipulated  by  the  patient  that  the 
surgeon  removed  his  appendix — in  good  faith. 

One  should  not  forget  the  possibility  of  painful  menstruation 
in  females. 

Iiitni-abdomiudl  ineustrnation  must  also  be  thought  of,  if  this 
c<mdition  is  really  diagnosable.  Such  cases  have  more  than  once 
been  operated  on  with  the  diagnosis  of  appendicitis. 

We  have  already  referred  to  intestinal  obstruction,  and  will  discuss 
it  in  detail  later  on. 

The  attacks  of  pain  induced  by  adhesions,  by  anomalies  of  position 
and  of  form,  belong  to  this  group.  If  the  history  and  skiagram  do 
not  afford  any  definite  guidance,  a  positive  diagnosis  can  only  be 
obtained  if  the  transitory  kink,  twist  or  band  leads  to  genuine  intestinal 
obstruction  with  a  subsequent  operation,  or  examination  post-mortem. 

Finally  it  must  not  be  forgotten  that  little  children  usually  refer 
the  pain  of  pneumonia  or  pleurisy  to  the  abdomen.  In  adults  also^ 
diaphragmatic  pleurisy  is  manifested  by  pain  on  one  side  of  the 
abdomen  and  muscular  contraction. 

The  pain  of  tubercular  caries  rarely  extends  so  far  into  the 
abdomen  as  to  cause  serious   diagnostic  difficulties. 

L\— DIFFUSE    PERITONITIS  WITHOUT  LOCALIZATION. 

The  second  group  of  cases  confronts  us  with  different  questions 
altogether.  The  physical  condition — accelerated  pulse,  pyrexia, 
general  tenderness,  a  rigidly  contracted  musculature  or  a  distended 
abdomen,  an  effusion,  either  free  or  badly  localized — shows  that  the 
peritoneum  is  acutely  inflamed.  The  diagnosis  of  nervous  disease  or 
colic  is  no  longer  possible. 

But  it  is  just  here  that  there  is  the  danger  of  confusing  obstruction 
with  peritonitis.  We  have  already  stated  the  main  points  of  the 
differential  diagnosis  at  the  beginning  of  this  chapter.     The  effusion,. 


264       SURGICAL   DISEASES    OF    THE    ABDOMINAL   AND    PELVIC    VISCERA 

which  SO  often  accompanies  strangulation  by  bands,  adds  to  the 
resemblance,  especially  as  peristalsis  is  frequently  inhibited  in  strangu- 
lation, thus  banishing  the  chief  svmptoni  of  difference  between 
peritonitis  and  obstruction. 

We  may  similarly  be  deceived  by  strangulation  due  to  a  pre- 
existing, but  frequently  overlooked  tubercular  peritonitis.  The 
tubercle  produces  the  exudation,  and  the  strangulation  evokes  the 
acute  symptoms. 

A  young  girl,  aged  18,  hitherto  quite  well,  except  for  some  vague 
indigestion,  was  suddenly  attacked  by  abdominal  pain,  vomiting  and 
fever.  Two  days  later  1  found  her  in  the  following  condition  :  high 
fever,  rapid  hardly  perceptible  pulse,  accelerated  respiration,  dry 
tongue,  red  flushes  on  face,  distended  sensitive  abdomen  with  dulness 
in  the  dependent  part.  Evervthing  pointed  to  a  generahzed  peritonitis 
subsequent  to  appendicitis.  But  there  was  one  sign  which  caused 
hesitation.  When  I  arrived  the  patient  was  sitting  half  up,  and  she 
resumed  this  posture  without  any  ditBculty  during  the  examination. 
A  patient  with  severe  peritonitis  never  does  this  ;  and  therefore  some 
other  diagnosis  had  to  be  found.  This  was  suggested  by  the  fact  that 
there  were  two  tubercular  uncles,  and  that  the  patient  had  previously 
suffered  from  digestive  trouble.  The  inference  was  that  the  case  was 
one  of  an  overlooked  tubercular  peritonitis  on  which  an  acute  obstruc- 
tion had  supervened — the  latter  condition  having  rapidly  reached  the 
stage  of  diffuse  distension  of  the  abdomen  and  rapid  small  pulse. 
Hence  this  picture  of  peritonitis.  This  diagnosis  was  confirmed  at 
the  operation. 

We  mav  also  be  deceived  bv  a  "  meso-cceliac "  appendicular 
abscess  Iving  between  or  behind  the  coils  of  the  small  intestine 
(fig.  i43t/).  These  abscesses  are  situated  too  high  to  allow  of  their 
being  felt  per  rectum.  If  the  forwardly  displaced  loops  of  small 
intestine  are  so  distended  that  the  abscess  cannot  be  felt  through  the 
abdominal  wall,  one  usuallv  thinks  of  generalized  peritonitis,  or  of 
obstruction,  unless  the  consideration  of  the  whole  course  of  the  illness 
leads  to  a  correct  diagnosis. 

There  are  vet  two  other  conditions  which  may  lead  us  astray,  viz., 
acute  pancreatitis  with  acute  fat  necrosis,  and  blocking  of  the 
mesenteric  vessels.  The  former  condition  is  suggested  when  the 
svmptoms  are  mainly  confined  to  the  upper  abdominal  region,  and 
the  patient  is  a  stout  man  of  middle  age  or  older.  The  presence  of 
sugar  in  the  urine  is  a  valuable  aid  to  diagnosis,  but  the  patients 
usually  succumb  before  the  onset  of  glycosuria. 

The  blocking  of  the  mesenteric  vessels  generally  concerns  an 
artery,  and  less  often  a  vein.  In  the  case  of  arterial  blocking,  the 
cause  is  either  embolism,  or  thrombosis  ;  when  a  vein  is  blocked  the 
cause  is  always  thrombosis.  The  anatomical  result  is  infarction,  or 
gangrene  of  a  more  or  less  considerable  section  of  the  intestine.  The 
earlv  clinical  signs  partake  of  the  character  of  peritonitis,  with  per- 
-sistent  deep,  dull  pain  and  effusion,  rather  than  that  of  obstruction. 


ACUTE    INFLAMMATION    WTTHIN    THE    ABDOMINAL    CAVITY         265 

Blood  in  the  stools,  and  the  vomiting  of  lumps  of  blood,  and  the 
retention  of  flatus,  should  arouse  suspicion.  The  existence  of  valvular 
disease,  indicates  embolism,  especial^  if  the  patient  has  manifested 
other  signs  of  embolism.  Diseased  blood-vessels,  and  general  defects 
of  the  circulation  would  point  to  thrombosis.  As  a  rule,  the 
embolism  is  first  recognized,  either  at  the  operation  or  at  the  autopsy. 

Having  established  the  diagnosis  of  acute  infective  peritonitis,  we 
must  endeavour  to  determine  its  origin.  The  considerations  with 
which  we  introduced  the  discussion  of  peritonitis  will  be  of  great 
assistance,  as  also  the  remarks  to  be  made  in  the  next  section  on 
localized  inflammatory  processes.  When  in  doubt,  we  must  suspect 
appendicitis,  at  any  rate,  in  civilized  countries.  In  other  regions  it 
may  be  otherwise,  because  this  disease  is  not  equally  prevalent 
everywhere. 

It  is  stated  that  only  whites  suffer  from  appendicitis  in  China  and 
South  x\frica.  It  is  uncertain  whether  this  is  a  matter  of  race  or  of 
nutrition, 

C.— LOCALIZED  PERITONITIS. 

If  there  are  clear  svmptoms,  pointing  to  a  localized  area  of  inflam- 
mation, our  task  is  much  easier,  whether  general  symptoms  are  present 
or  not.  We  will  proceed  topographically,  starting  with  the  upper 
portion  of  the  abdominal  cavity. 

(1)   EPIGASTRIUM. 

The  most  frequent  origin  of  inflammation  in  the  epigastrium  is  in 
the  stomach,  and  the  cause  is  either  a  gradual  or  sudden  perforation 
of  an  ulcer,  or  more  rarely  of  cancer.  Perforation  of  a  duodenal  ulcer 
close  to  the  pylorus  causes  identical  symptoms.  Pancreatic  haemor- 
rhage and  pancreatitis,  which  we  have  already  referred  to,  should 
also  be  mentioned.  Exceptionally,  a  hepatic  abscess  may  be  situated 
in  the  middle  of  the  epigastrium. 

(2)    RIGHT    HYPOGHONDRIUM. 

In  temperate  climates  the  bile  ducts  are  mainly  responsible  for 
inflammation  in  this  region,  with  extension  into  the  liver  substance  in 
the  form  of  septic  cholangitis.  In  the  Tropics,  abscess  of  the  liver  is 
the  most  frequent  occurrence.  This  does  not  exclude  the  possibility 
of  hepatic  abscess  in  temperate  climes,  but  then  the  abscess  is  gener- 
ally the  result  of  gall-stone  disease,  wliich  is  predominant  clinically,  or 
it  is  metastatic  in  nature,  and  recedes  into  the  background  in  comparison 
with  the  other  signs  of  the  pyaemia.  Rupture  of  a  duodenal  ulcer 
must  next  be  mentioned.     If  the  rupture  has  been  gradual  it  causes  a 


266       SURGICAL   DISEASES    OF   THE   ABDOMINAL   AND    PELVIC   VISCERA 

localized    inflammation,   if    it   has   been  sudden  it  causes  generalized 
peritonitis. 

We  shall  see  later  on  that,  occasionally,  a  vermiform  appendix  may 
wander  into  this  region. 

(3)    LEFT   HYPOCHONDRIUM. 

Inflammatory  processes  occurring  in  this  vicinity,  are  nearly  always 
the  result  of  perforated  gastric  ulcers.  Abscess  of  the  spleen  is 
very  rare,  but  it  has  been  observed  especially  in  typhoid  fever.  In 
cases  of  appendicitis,  secondary  abscesses  often  occur  in  the  left 
hypochondrium,  or  travel  up  into  this  region  from  below. 

(4)   LUMBAR    REGIONS. 

Rctro-pcritoiieal  inflammation  in  the  lumbar  region  is  mainly  con- 
cerned with  the  kidney.  If  the  inflammation  has  extended  so  far 
forward  that  we  must  assume  that  the  pcriioiicum  is  involved,  then  on 
the  right  side,  we  should  first  think  of  appendicitis  (fig.  143,^').  This 
diagnosis  is  obvious  if  the  ileo-caecal  region  is  also  involved.  On  the 
other  hand  I  have  seen  experienced  practitioners  in  doubt,  even  where 
tliis  area  has  been  quite  free,  and  when  the  whole  process  has  been 
confined  to  the  lumbar  region.  The  lumbar  varietv  of  appendicitis  is, 
however,  not  always,  intra-peritoneal.  When  the  appendix  is  in  this 
position,  it  is  usually  either  entirely  or  partially  retro-peritoneal,  so 
that  the  peritonitic  symptoms  are  not  predominant,  and  the  disease 
process  tends  toward  the  back,  appearing  as  a  phlegmon  of  the 
cellular  tissue  attended  by  high  fever  (fig.  143,  /). 

Very  significant  of  this  form  of  phlegmon,  which  usually  contains 
gas-forming  bacteria,  is  the  change  of  the  reddened  skin  into  a 
3'ellowish  hue.  It  cannot  be  a  mere  accident  that  I  have  seen  so 
many  of  these  cases  end  in  pyaemia. 

Appendicitis  is  often  the  cause  of  apparently  primary  abscesses  of 
the  left  lumbar  region.  In  these  cases,  the  appendix  lies  in  a  very 
dependent  position,  and  the  primary  abscess,  which  is  not  palpable 
from  above,  originates  in  the  true  pelvis  (fig.  143,  e),  and  then 
advances  towards  the  left. 

It  should  finally  be  mentioned  that  parametritis  often  extends 
towards  the  lumbar  region. 

(5)  LOWER   ABDOMINAL    REGION. 

(a)  If  an  inflammatory  process  occurs  in  a  female,  exactly  in  the 
middle  line,  our  first  thought  must  turn  to  the  uterus  and  its  vicinity, 
and  we  must  not  be  misled  either  by  the  married  or  single  state  of 
the  patient.  If  we  do  not  at  once  ascertain  that  the  disease  has 
followed  a  confinement   or  miscarriage,  we   enquire   about   the   last 


ACUTE    IXFLAMMATIOX    WITHIX    THE    ABDOMINAL    CAVITY 


267 


menstruation,  and  the  more  hesitating  the  reply  the  stronger  are  our 
suspicions.  Experience  shows  that  nearly  all  infections  which  follow 
miscarriages  are  due  to  the  use  of  the  sound  in  procuring  abortion^ 
Sometimes  it  happens  that  an  apparently  in.flammatory  swelling 
situated  directly  in  the  middle  line  of  the  lower  abdominal  region  is 
really  due  to  an  extra-uterine  gestation,  concerning  which  more  will  be 
said  later  on.  If  the  clinical  hi^torv  and  vaginal  examination  exclude 
disease  of  the  genital  organs,  we  must  look  elsewhere  for  the  cause 
of  the  trouble,  and  again  we  fall  back  upon  the  appendix,  which  i> 
otten  responsible  for  a  primary  abscess  in  the  middle  Ime. 

In  rare  instances  a  perforated  Meckel's  Diverticulum  causes  a 
median  abscess,  or  one  situated  rather  more  to  the  right  beneath  the 
umbilicus.  This  is  also  the  favourite  place  for  the  pointing  of  an 
abscess    due  to    pneumococcal    peritonitis    in    little    girls.     If   these 


Fig.    142. — Pneumococcal  peritonitis  on  the  point  of  bursting  through  the  umbilicus. 


abscesses  are  not  opened  in  time,  they  eventually  burst  through  the 
navel  (fig.  142).  Thev  are  distinguished  from  other  abdominal 
abscesses  by  their  remarkable  softness. 

Ovarian  cysts  with  twisted  pedicles  or  which  have  suppurated 
are  usually  situated  in  the  middle  line.  A  superficial  examination  is 
liable  to  mistake  them  for  abdominal  abscesses,  or  for  appendicitis  if 
they  are  situated  towards  the  right  side.  Their  sharply  defined  upper 
border  should  usually  establish  the  diagnosis.  Twisting  of  the  pedicle 
is  comparatively  frequent,  while  suppuration  of  an  ovarian  cyst  is 
rare.  The  former  condition  is  very  sudden  in  its  onset,  and  to  some 
extent  is  distinguished  from  a  suppurating  ovarian  tumour  by  the 
course  of  the  temperature.  In  the  latter,  the  leucocyte  count  of  the 
blood  is  high. 
18 


268 


Fig 


143- 


Diagrammatic    Kepresentation   of  the  more  Important   Phases  and    Forms   of  Appendicitis, 
and  of  some  Considerations  in  Differential  Diagnosis. 
Green  =  abscess  contiguous  to  the  anterior  abdominal  wall. 
Shaded  green  =  abscess  covered  by  intestine. 

Yellow  =  serous  or  sero-puiulent  exudation,  aseptic  on  first  day,  infected  early  exuda- 
tion on  second  day. 
Yellowish-green  =^  sero-purulent  exudation. 
Blue  =  extra  peritoneal  abscess. 
Red  =  blood  effusion. 


Appendix  forwards  and  inwards.  Appen- 
dicitis, antero-parietal.  First  stage.  Puru- 
lent appendicitis.  Localized  serous  peri- 
appendicitis.    (Early  exudation  beginning.) 


Same  form.  Second  stage,  second  to  third 
day.  Purulent  peri-appendicitis  beginning. 
Extensive  early  exudation. 


Same  form  at  end  of  first  week.  Third 
stage.  Large  antero-parietal  encapsuled 
abscess.     Early  exudation  has  subsided. 


Same  stage,  but  appendix  situated  in 
convolution  of  small  intestine.  Abscess 
covered  by  intestinal  loop.  Meso-coeliac 
appendicitis. 


Same   stage.      Appendix   ia   true    pelvis. 
Pelvic  appendicitis. 


Same  stage.     Appendix  situated  outwards 
and  downwards.     Ileo-inguinal  appendicitis. 


ii) 
Same  stage.     Appendix  directed  upwards 
and    outwards.       Abscess     partially    behind 
CEECum.     Ileo-lumbar  intra-peritoneal  appen- 
dicitis. 


Same  stage.  Caecum  and  appendix  drawn 
upwards.  (Beginning  of  left-sided  trans- 
position of  colon.  Common  ileo-ccecal 
mesentery.)  Sub-hepatic  appendicitis.  (Ab- 
scess in  same  position  when  ciscum  is  normal, 
but  when  very  long  appendix  is  drawn 
upwards   and  outwards.) 


270 


Fig.   143. 


Diffuse  sero-purulent  peritonitis,  in  a  very 
virulent  infection,  large  perforation  or  gan- 
grene of  appendix,  or  secondary  rupture  of 
encapsuled  abscess.  This  form  of  peritonitis 
is  fatal,  or  recovery  only  occurs  with  abscesses 
remaining. 


Multiple  abscesses  (residual)  after  general 
sero-purulent  or  purulent  peritonitis.  The 
figure  shows  the  most  common  positions. 
These  abscesses  frequently  intercommunicate, 
thus  a  and  b,  often  a  and  c,  or  a  and  d,  &c. 
The  "progressive  fibrinous  purulent  peri- 
tonitis" of  Mikulicz  and  Burckhardt  depends 
upon  this  process. 


Appendix  inclined  upwards  and  outwards. 
The  abscess  is  extra-peritoneal,  sub-serous 
and  finally  became  superficial  in  the  form  of  a 
phlegmon  in  the  lumbar  region.  Lumbar 
appendicitis  or  ileo-lumbar  sub-serous  appen- 
dicitis. 


The  abscess  is  under  the  iliacus  fascia.  Ileo- 
inguinal  sub-fascial  appendicitis.  The  abscess 
may  reach  the  thigh  by  tracking  under 
Poupart's  ligament. 


ACUTE    INFLAMMATION   WITHIN    THE    ABDOMINAL   CAVITY  2/1 


Fig.   143. 


(«)  (0) 

Purulent  peritonitis,    exciting  serous  peri-         Bilateral  pyosalpinx,  with  some  serous  peri- 
tonitis in  the  vicinity.     U  =  uterus.  salpingitis. 


Parametritis  extending  as  far  as  Poupart's 
ligament. 


Rupture  of  a  pregnant  tube.     P  =  placenta, 
with  a  peri-tubal  haematoma  around. 


272       SURGICAL   DISEASES   OF   THE   ABDOMINAL   Ax\D    PELVIC   VISCERA 

Abscesses  in  the  abdominal  wall,  below  the  umbilicus  and  above 
the  symphysis,  must  not  be  mistaken  for  abdominal  abscesses.  The 
sub-umbilical  abscesses  usually  arise  from  infective  disease  of  the 
peritoneum,  while  those  above  the  symphysis  originate  either  in 
some  infective  trouble  of  the  urinary  tract  or  from  osteomyelitis  of 
the  pubis.  The  sensation  that  the  abscess  is  immediately  beneath  the 
hand,  and  the  absence  of  intestinal  symptoms  with  the  occasional 
presence  of  bladder  disturbance,  makes  the  diagnosis  quite  easy. 

(6)  If  the  resistance  is  at  tlie  side  we  are  fully  justified  in  thinking 
of  the  appendix  on  the  right,  and  we  shall  often  have  to  assume  the 
same  origin,  even  if  the  abscess  is  on  the  left  side,  in  males.  In 
females  we  must  think,  in  addition,  of  salpingitis,  parametritis,  extra- 
uterine pregnancy,  and  more  often  than  in  males,  also  of  the 
gall-bladder. 

It  should  be  added  that  the  position  of  the  diseased  area,  in 
appendicitis,  is  not  always  at  McBurney's  spot,  between  the  anterior 
superior  spine  of  the  ileum  and  the  umbilicus  ;  indeed  it  is  usually 
not  there.  The  appendix,  as  we  shall  see  later  on,  varies  very  much 
in  its  position  (fig.  143,  a,  d,  g,  Ji). 

We  first  consider  the  history.  If  abdominal  pain  and  vomiting 
constituted  the  onset,  and  similar  attacks  have  preceded,  the  case 
is  probably  appendicitis  or  may  be  cholelithiasis.  If  the  symptoms 
have  come  on  with  the  menstruation,  or  if  they  have  apparently 
brought  it  on  early,  this  should  not  tempt  us  from  the  first  diagnosis. 
But  if  the  illness  has  followed  a  miscarriage  or  a  confinement  and 
is  not  accompanied  by  signs  of  peritonitis,  we  can  only  assume  that 
it  is  a  case  of  phlegmon  of  the  broad  ligament  (fig.  143,  p). 

The  following  case  serves  as  an  example  for  diagnosis  :  A  woman, 
aged  38,  was  brought  in,  for  a  suspected  strangulated  hernia.  She 
was  three  months  pregnant,  and  had  a  threatened  abortion  a  few 
days  before.  No  haemorrhage  now.  There  was  a  hard  swelling  in  the 
right  hypogastrium,  reaching  below  Poupart's  ligament.  There  were 
prominent  lung  symptoms  and  blood-stained  sputum.  Many 
examinations  were  made  and  many  diagnoses  suggested.  Contra- 
dictory statements  regarding  origin  of  symptoms.  Suspicion  of 
criminal  abortion,  with  injury  to  right  vaginal  vault  and  phlegmon 
of  right  cellular  tissue,  venous  thrombosis  and  pulmonary  embolism. 
Uterus  apparently  not  afl^ected,  as  there  was  neither  pain  nor  haemor- 
rhage. Per  vagiiiani,  uterus  three  months  pregnant,  somewhat  fixed 
on  the  right.  Circumscribed,  hard  infiltration  of  mucous  membrane 
in  right  vaginal  vault.  Right-sided  parametritis.  Speculum  showed 
that  the  portio  was  uninjured,  that  there  was  a  thrombosed  varix  with 
two  wounds  of  the  mucous  membrane,  a  few  millimetres  each,  in 
the  right  vaginal  vault.  These  could  have  been  inflicted  by  a  knitting 
needle  or  similar  instrument.  The  threatened  abortion  was  therefore 
a  haemorrhage  from  a  perforated  varix,  upon  which  followed  infective 
thrombosis,  phlegmon  of  pelvis  and  thigh,  pulmonary  embolism  and 
multiple  abscesses, — and  finally  the  patient  recovered. 


ACUTE    INP"LAMMATION    WITHIN    THE    ABDOMINAL    CAVITY         273 

A  cylindrical  or  irregularly  circular  sharply-defined  swelling  at  the 
border  of  the  true  pelvis  and  the  iliac  fossa,  which  has  taken  months 
or  years  to  form,  is  a  salpingitis.  In  its  development,  frequent,  but 
not  severe  inflammatory  attacks  occur,  and  careful  investigation  will 
generally  reveal  a  history  of  gonorrhoea  or  tubercle.  The  disease  may 
be  unilateral  or  bilateral  (fig.  143,  0).  The  history  of  gonorrhoea  can 
only  be  obtained  by  confidential  questioning  of  the  husband,  if  there 
be  one.  If  we  are  informed  that  irregular  haemorrhage  occurred  after 
one  or  two  periods  had  been  missed,  and  that  the  lateral  swelling 
which  we  detect  has  been  accompanied  by  severe  pain,  collapse  and 
perhaps  by  vomiting,  we  shall  seldom  go  wrong  in  diagnosing  a 
ruptured  tubal  gestation,  or  a  tubal  abortion  (fig.  143,  q). 

We  derive  most  information  from  physical  examination.  By  this 
method  we  are  able  to  define  morbid  conditions  above,  towards  the 
gall  bladder,  as  well  as  those  below,  towards  the  pelvic  organs.  If 
the  resistance  is  more  clearly  limited  below  than  above,  and  if  the 
maximum  point  of  pain  on  pressure  is  high  up  we  should  think  of 
disease  of  the  bile  ducts.  If  the  gall  bladder  is  greatly  enlarged  and 
inflamed,  this  point  of  maximum  pain  may  be  displaced  below  the 
line  of  the  umbilicus,  especially  if  the  adjacent  loops  of  intestine  are 
involved  in  the  inflammation.  Jaundice  naturally  points  to  biliary 
disease,  but  not  unconditionally,  any  more  than  the  absence  of 
jaundice  is  an  argument  against  it.  The  age  of  the  patient,  whether 
male  or  female,  is  of  significance;  as  the  probability  of  cholelithiasis 
increases  with  age. 

If  the  morbid  process  tends  downwards,  we  decide  upon  appendi- 
citis if  the  pain  and  the  maximum  point  of  tenderness  on  pressure  are 
found  above  the  true  pelvis,  while  the  symptoms  are  definitely  less, 
lower  down.  On  the  other  hand,  we  diagnose  parametritis,  if  the 
swelling  and  tenderness  have  started  close  to  the  uterus,  whence  they 
have  spread  upwards  towards  Poupart's  ligament,  or  even  to  the  pelvic 
fossa  or  lumbar  region.  Vaginal  or  rectal  examination  may  detect 
a  perityphlitic  exudation  reaching  into  the  true  pelvis,  beliiiid  the 
uterus,  or  an  extra-peritoneal  parametritic  exudation  at  the  side  of 
the  uterus,  displacing  it  towards  the  healthy  side,  and  more  or  less 
fixed  to  the  pelvis.  In  a  case  of  extensive  pyosalpinx,  a  more  or  less 
sausage-shaped,  sharply  defined  resislance  can  be  felt  from  above,  and 
its  connection  with  the  uterus  can  be  made  out  by  bi-manual  examina- 
tion. But  even  apart  from  this,  the  sharply  defined  limitation  of  the 
structure  facilitates  its  distinction  from  an  acute  perityphlitic  abscess. 

The  frequent  exacerbations  of  peri-salpingitis  occurring  in  a  pyo- 
salpinx render  the  diagnosis  difficult.  But  even  in  these  instances 
the  limitation  above  is  quite  sharp,  which  is  not  often  the  case  with 
appendicitis. 


274       SURGICAL    DISEASES    OF   THE    ABDOMINAL    AND    PELVIC    VISCERA 

The  diagnosis  of  a  ruptured  right-sided  pyosalpinx  is  difficult. 
The  following  is  a  typical  case.  A  girl  aged  20  was  seized  at  night, 
after  a  festive  occasion,  with  "  appendicitis,"  and  was  admitted  within 
twenty- four  hours  with  the  symptoms  of  a  commencing  diffuse 
peritonitis.  Temperature  was  io4'8  F.,  face  was  remarkably  flushed. 
Indefinite  resistance  was  felt  on  the  right  side,  per  rectum.  As  the 
flushed  face  was  very  unusual  for  appendicitis,  and  as  the  height 
of  the  temperature  was  still  more  unusual  for  the  first  day,  we 
thought  of  rupture — sub  coitu  ? — of  a  right  tube,  and  the  operation 
confirmed  the  diagnosis.  The  pus  contained  a  pure  culture  of 
SfapJiylococciis  aureus. 

Cases  wherein  an  acute  appendicitis  becomes  engrafted  on  an  old 
salpingitis  are  not  very  rare,  but  it  is  quite  impossible  to  unravel 
the  maze  of  symptoms  and  make  a  diagnosis. 

There  may  not  be  any  less  difficulty  in  differentiating  between 
appendicitis  and  a  ruptured  tubal  gestation.  The  swelling  is 
situated  midway  betw^een  the  position  of  an  appendicular  abscess  and 
a  parametritis.  It  is  intra-peritoneal  like  the  former,  but  connected 
with  the  uterus  like  the  latter.  It  often  reaches  as  far  as  the  appendix, 
so  that  the  roof  of  the  blood  cavity  is  formed  by  the  appendix,  caecum 
and  last  loops  of  the  small  intestine,  all  combined. 

On  one  occasion  I  found  a  shrivelled  foetus  of  about  ten  weeks 
gestation  tucked  away  with  a  thrombosed  placenta  under  the  caecum. 

It  will  of  course  be  understood  that  the  oval  swelling  close 
to  the  uterus  is  only  one  of  the  symptoms  of  ruptured  tubal  gesta- 
tion, or  of  tubal  abortion,  i.e.,  the  peri-iubal  Iweuiatouia.  If  the 
history  is  indefinite  or  unreliable,  it  may  be  very  difficult  to  dis- 
tinguish it  from  a  unilateral  pyosalpinx  in  which  peri-salpingitis 
has  occurred — as  gynaecologists  know  very  well. 

If  the  haemorrhage  is  severe  or  is  repeated,  then  the  haema- 
toma  is  no  longer  lateral,  but  becomes  retro-uterine,  and  should 
rarely  be  confused  with  an  appendix  abscess  in  the  pelvis.  But 
if  there  should  be  any  doubt,  extra-uterine  gestation  is  confirmed 
by  softening  of  the  vaginal  cervix,  enlargement  of  the  breasts, 
the  exit  of  drops  of  milky  fluid  when  they  are  squeezed,  anaemia 
and  slight  jaundice.  The  presence  of  fever  is  no  contra-indication. 
A  glance  at  the  patient's  ears  is  the  most  rapid  indication  of  the 
degree  of  anaemia.  Their  marked  pallor  is  as  significant  of  a  severe 
internal  haemorrhage  as  their  blueness  is  of  peritonitis,  other  sym- 
ptoms being  equal.  If  some  abnormal  swelling  can  be  felt  in 
Douglas'  pouch  in  the  first  twenty-four  hours,  the  case  is  probably 
a  haematocele,  because  appendicitis  does  not  lead  to  an  abscess  in 
Douglas'  pouch  so  soon.  If,  on  the  other  hand,  the  history  points 
to  extra-uterine  pregnancy,  and  the  tumour  is  strikingly  movable, 
we  must  think  of  an  unruptured  tubal  gestation  or  of  an  abdominal 
pregnancy.  Too  energetic  an  examination  may  cause  a  severe 
haemorrhage  in  such  a  case. 

The  condition  of  the  abclouiinal  luuscles  is  important  in  a  doubtful 
case.     The  degree  of  their  reflex  spasm  depends  upon  the  nature  and 


ACUTE    INFLAMMATION    WITHIN    THE    ABDOMINAL   CAVITY         275 

intensity  of  the  irritation,  and  the  extent  to  which  it  has  involved 
the  anterior  abdominal  wall.  It  is  most  pronounced  in  appendicitis, 
less  so,  or  absent  in  salpingitis  and  ruptured  tubal  gestation.  In  the 
latter  case,  it  depends  upon  the  extent  of  contact  of  the  haematoma 
with  the  abdominal  wall,  and  the  sensitiveness  of  the  individual 
towards  an  intra-peritoneal  effusion  of  blood.  It  should  also  be 
remarked  that  individual  differences  in  reflex  irritability,  and  the 
special  characteristics  of  the  micro-organisms  concerned,  play  an 
important  role,  even  in  suppurative  diseases.  The  blood  examination 
is  of  value,  in  so  far  as  a  great  decrease  in  the  haemoglobin  and 
red  corpuscles  indicates  haemorrhage.  But  leucocytosis  does  not 
necessarily  indicate  an  inflammatory  process,  because  this  may  occur, 
even  in  an  extreme  degree,  in  ruptuied  tubal  pregnancy. 

If  the  displacement  of  gas  from  the  descending  colon  towards  the 
caecum,  by  pressure  upwards  from  the  left  of  the  pelvic  fossa,  causes 
pain  in  the  appendix,  this  always  means  appendicitis,  according  to 
Rovsnig,  or,  at  any  rate,  some  inflammatory  process  involving  the 
caecum.  I  agree  with  Hausmann,  that — at  any  rate  in  many  cases — 
the  pressure  is  communicated  to  the  inflamed  area,  not  by  the  column 
of  gas  in  the  large  intestine,  but  through  the  distended  small  intestine. 

Diseases  of  the  left  side  of  the  pelvis  require  mention,  although 
they  only  half  belong  to  the  surgeon.  He  shares  the  diseases  of  the 
female  genitalia  with  the  gynaecologist,  on  account  of  the  frequency 
of  errors  of  diagnosis.  The  physician  occasionally  refers  to  him  cases 
of  sigmoiditis,  i.e.,  localized  subacute,  or  acute,  inflammation  of  the 
sigmoid  flexure.  This  condition  should  be  thought  of,  when  a 
sausage-shaped  swelling  is  felt  in  the  left  lower  abdominal  region,  in 
association  with  symptoms  of  colitis  :  diarrhoea,  mucous  discharge  and 
blood.  It  is  still  a  medical  disease  in  this  stage,  but  if  signs  of  peri- 
sigmoiditis, i.e.,  irritation  of  the  peritoneum,  supervene,  the  cases 
become  surgical  and  the  question  of  operative  assistance  arises.  We 
shall  refer  to  this  again  in  another  connection. 


(6)  TRUE    PELVIS. 

To  discuss  inflammations  within  the  true  pelvis  is  apparently  an 
intrusion  into  the  province  of  gynaecology.  We  may,  however,  dis- 
arm this  criticism  by  beginning  with  the  male  sex.  It  often  happens 
that  nothing  can  be  felt  in  the  whole  abdomen,  and  then  it  is  found 
that  Douglas'  pouch  is  occupied  by  an  inflammatory  swelling.  What 
may  this  be  ?  It  is  most  probably  an  appendicular  abscess,  origi- 
nating in  an  appendix  hanging  down  into  the  true  pelvis.  But  I  have 
found  there  an  intussusception  of  the  small  intestine,  which  I  looked 
upon  as  an  appendicitis  until  the  operation.  An  inflamed  coil  of 
small  intestine,  obstructed  by  a  gall-stone  is  often  found  in  the  true 
pelvis.  Cancer  of  the  rectum  often  gives  rise  to  peri-rectal  suppura- 
tion.    Finally,  there  occur  abscesses  arising  from  the  urinary  tract, 


276       SURGICAL    DISEASES    OF   THE    ABDOMINAL   AND    PELVIC    VISCERA 

which  are  speciall}^  to  be  attributed  to  prostatic  suppuration,  of 
suppurating  diverticula,  in  prostatic  patients. 

A  rare  cause  of  inllammation  may  be  mentioned  here,  as  arising 
from  the  multiple  diverticula  of  the  descending  colon,  varying  in 
size  from  a  millet-seed  to  a  cherry-stone,  which  have  been  described 
especially  by  Graser. 

With  the  exception  of  prostatic  suppuration,  all  the  above  con- 
ditions also  apply  to  the  female  sex,  who  also  suffer  from  the  special 
diseases  associated  with  the  female  genitalia.  Some  controversy  has 
raged  around  the  proper  limitations  of  the  work  of  the  surgeon  and 
gynjecologist.  In  order  to  avoid  this,  I  will  only  mention  here  the 
association  of  pregnancy  or  the  puerperal  state  with  appendicitis. 
When  pains  occur  in  the  hypogastrium  of  a  pregnant  woman  we 
naturally  connect  them  wnth  the  pregnancy,  but  the  possibility  of 
appendicitis  must  not  be  overlooked.  This  combination  is  most 
unfortunate,  as  it  generally  leads  to  abortion,  or  miscarriage.  If  the 
pregnant  uterus  forms  a  portion  of  the  abscess  wall,  as  is  usually  the 
case,  rupture  of  the  abscess  is  almost  inevitable,  and  therewith  fatal 
peritonitis  also.  The  midwife  or  doctor  is  usually  blamed  for  this, 
unless  an  autopsy  throws  light  on  the  tragedy.  I  have  seen  a  similar 
catastrophe  at  the  end  of  a  normal  pregnancy. 

For  this  reason,  one  should  not  shirk  removing,  during  pregnancy, 
an  appendix  threatened  with  inflammation.  If  an  abscess  has  formed 
it  is  imperative  to  open  it  before  abortion  or  labour  occurs. 

It  is  sometimes  very  difficult  to  distinguish  exacerbations  of  acute 
(generally  of  gonorrhoeal  origin)  salpingitis,  which  occasionally  occur 
in  the  puerperal  period,  from  attacks  of  appendicitis,  especially  when 
there  is  a  previous  history  of  appendix  seizures. 


CHAPTER  XXXVII. 

SUB-PHRENIC  ABSCESS. 

If  a  patient  has  continuous  high  fever  without  any  obvious 
suppuration  in  any  of  the  easily  accessible  regions  of  the  body,  we 
should  bear  in  mind  the  various  possibilities  of  sub-phrenic  abscess. 
The  existence  of  such  an  abscess  is  highly  probable,  if  the  patient  has 
recently  had  any  inflammatory  disease  within  the  abdominal  cavity. 
About  half  the  cases  of  sub-phrenic  abscess  originate  in  appendicitis  ; 
the  rest  are  due,  in  the  abundant  experience  of  Korte,  to  affections  of 
the  stomach,  liver,  spleen,  kidneys,  pleura,  ribs,  intestine  and  pancreas 
— in  descending  proportion. 


SUB-PHRENIC   ABSCESS 


277 


The  main  aid  to  the  diagnosis  of  sub-phrenic  abscess  is  to  bear  it 
in  mind  and  search  for  it.  We  shall  describe  a  typical  case  before 
detailing  the  symptoms. 

A  young  man  passed  through  a  severe  attack  of  perityphlitis, 
which  was  operated  on,  in  the  stage  of  widespread  peripheral  peri- 
tonitis. All  the  symptoms  gradually  abated.  The  temperature  rose 
again  two  months  after  the  beginning  of  the  illness,  but  examination 
with  the  view  of  detecting  a  sub-phrenic  abscess  revealed  nothing. 
But  as  the  fever  persisted,  the  patient  was  re-examined.  The  lower 
border  of  the  liver  was  at  first  in  the  normal  position,  its  dulness  did 
not  extend  upwards  above  the  usual  limit  ;  the  condition  of  the  lung 
was  normal  and  there  was  a  complete  absence  of  subjective  symptoms. 
A  small  patch  of  broncho-pneumonia  on  the  left  side  misled  us  and 
prevented  us  from  making  an  immediate  exploratory  puncture  on 
the  right  side.  Eventually  the  liver  dulness  began  to  extend  upwards 
and  its  lower  border  downwards,  and  slight  pain  on  breathing  super- 
vened. This  confirmed  our  suspicion.  Screen  examination  by 
X-rays  showed  normal  movements  of  the  right  arch  of  the  diaphragm, 
but  its  shape  was  remarkably  semi-spherical  and  it  appeared  to  be 
very  high.  Exploratory  puncture  and  immediate  operation  demon- 
strated a  sharply  localized  sub-phrenic  abscess,  which  caused 
considerable  upward  bulging  of  the  diaphragm. 

The  diagnosis  is  rendered  very  difficult  by  the  fact  that  percussion 
over  the  lung  as  well  as  over  the  abscess  may  yield  very  varying 
results.  The  lung  may  give  a  normal  note,  or  a  dull  note  if  there 
be  any  associated  pleurisy,  whereas  a  sub-phrenic  abscess  will  be 
tympanitic  if  it  contain  gas;  otherwise  it  will  be  dull.  The  situa- 
tion of  the  abscess  is  not  constant,  sometimes  it  is  confined  to  the 
upper  surface  of  the  liver,  sometimes  its  position  is  more  forwards, 
at  others  it  is  situated  backwards  and  downwards,  in  which  case 
it  resembles  a  peri-renal  abscess.  We  will  treat  this  subject  in  two 
parts,  corresponding  to  the  fundamental  difference  of  the  presence 
or  absence  of  pleural  effusion. 

(1)  SUB-PHRENIC   ABSCESS   WITHOUT    PLEURAL 
EFFUSION. 

If  the  abscess  contains  little  or  no  gas,  as  in  the  previously  described 
case,  the  only  local  sign  is  that  the  edge  of  the  liver  is  lower,  whereas 
its  upper  border  of  dulness  is  higher.  The  lower  limit  of  the  healthy 
respiratory  sounds  is  also  pushed  upwards,  corresponding  to  the  liver 
dulness.  There  may  be  more  or  less  definite  signs  of  compression, 
but  they  may  be  quite  absent.  How  can  we  distinguish  this  physical 
condition  from  pleural  effusion  ?  The  degree  of  the  downward  dis- 
placement of  the  liver  and  the  bulging  of  the  lower  part  of  the  thorax, 
in  sub-phrenic  abscess,  are  too  variable  to  be  of  any  value  as  differen- 
tiating signs.      Very  marked    signs    of    pulmonary  compression  and 


278       SURGICAL    DISEASES    OF    THE    ABDOMINAL    AXD    PELVIC    VISCERA 


infiltration  point  to  empvenia  ;  if  these  signs  are  absent  thev  are  in 
favour  of  sub-phrenic  abscess.  But  it  is  more  important  to  reahze 
that  the  upper  border  of  the  duhness  in  sub-phrenic  abscess  is  convex, 
whereas  m  empvema  it  is  rather  liorizontal  or  runs  (jbliquely  towards 
the  spine.  A  screen  examination  by  X-rays  is  of  great  value,  and  its 
result  furnishes  even  stronger  evidence.  The  shadow  cast  in  empvema 
is  either  horizontal,  or  oblique  towards  one  side  or  the  other,  mostly 
towards  the  spme,  whereas  in  sub-phrenic  abscess  it  is  convex  upwards. 

But  the  history  is 
most  conclusive. 
Empyema  usually 
follows  some  dis- 
ease of  the  lung  ; 
a  sub-phrenic  ab- 
scess is  the  con- 
sequence of  an 
infective  process 
within  the  abdo- 
men. But  as  a 
secondary  pleurisy 
15  of  frequent  oc- 
currence in  this 
latter  condition, 
we  must  take  into 
consideration  the 
manner  in  which 
the  secondary  ill- 
ner-s  has  started. 
A  secondary  pleu- 
risy arises  after  the 
manner  of  an  em- 
bolism, and  sets 
in  with  more  or 
less  sudden  and 
severe  respira- 
tory difficulty ;  but 
a  s  u  b  -  p  h  r  e  n  i  c 
abscess  develops  slowly,  and  does  not  as  a  rule  cause  pain  until  it 
has  attained  a  definite  "size.  The  pain  is  also  much  duller  than  the 
pleuritic  pain  which  makes  the  breathing  so  difiicult.  If  a  pleurisy 
should  subsequently  develop  into  a  sub-phrenic  abscess,  it  will  be 
obvious  from  the  chronological  order  of  the  symptoms  that  the  latter 
was  not  the  original  trouble. 

In  anv  case  we  should  not  be  satisfied  with  the  demonstration  and 


Fig.  144. — Green  =  pus  in  contact  with  the  chest  wall. 
Collections  of  pus  in  contact  with  the  chest  wall.  On  the 
right  side,  the  usual  basal  empyema  ;  on  the  left,  interlobar. 


SUB-PHREXIC    ABSCESS 


2/9 


evacuation  of  a  serous  pleural  effusion,  if  the  symptoms  have  set  in 
gradually  and  a  high  temperature  persists.  If  the  effusion  is  sterile, 
the  presence  of  a  sub-phrenic  abscess  is  at  any  rate  extremelv 
probable. 

The  diagnosis  is  easier  if  the  abscess  contains  much  gas,  for  per- 
cussion will  yield  the  well-known  zones  :  below,  dulness  corresponding 
to  the  liver  and  the  fluid  contents  of  the  abscess,  then  a  tympanitic 
note  due  to  the  gas,  and  finallv  the  normal  note  of  the  lung 
(fig.  144).  This 
also  applies  to  the 
left  side,  uuitcitis 
inntaiidls.  An  ab- 
scess which  con- 
tains no  gas  is 
more  easily  recog- 
nizable on  the  left 
than  on  the  right, 
because  of  the  ex- 
tensive dulness 
and  the  displace- 
ment of  the  spleen 
downwards;  some- 
times also  by  the 
upward  displace- 
ment of  the  heart. 
If  the  abscess  con- 
tains gas  the  three 
zones  just  men- 
tioned can  be  de- 
tected. 

The  large  gas- 
containing  ab- 
scesses described 
of  old  are  seldom 
seen  nowadays,  be- 
cause thev  are  not  ^^^-  I45- — Shaded  green  =  pus  beneath  lung  and  diaphragm. 
11  .  ^  "  lv  •  i.  VeIlow  =  serous  effusion.  Black  =  air  vesicle.  The  chest  wall  in  contact 
allow  ea  SUrnCient  ^vith  collections  of  pus.  On  the  right,  a  sub-phrenic  abscess  with  gas 
tmie  to  develop.  vesicle  and  serous  pleural  effusion  ;  on  the  left,  an  abscess  of  lung. 


(2)  SUB-PHRENIC  ABSCESS  WITH   PLEURAL  EFFUSION. 

The  conditions  are  much  more  complicated  if  there  is  a  pleural 
effusion  in  addition  to  the  sub-phrenic  abscess.  On  the  right  side 
it  is  quite  impossible  to  make  a  definite  diagnosis  from  phvsical 
examination  alone,  because  of  the  normal  presence  of  the  liver 
dulness.     The  etioloi^v  and  course  of  the   illness  must  be  taken  into 


28o       SURGICAL   DISEASES    OF   THE   ABDOMINAL   AND    PELVIC   VISCERA 

consideration.  A  skiagram  may  yield  some  information,  because  the 
serous  effusion  will  be  more  transparent  than  the  greatly  bulged 
arch  of  the  diaphragm.  It  is  easier  to  differentiate  on  the  left  side, 
between  a  sub-phrenic  abscess  and  a  simple  pleural  effusion,  because 
of  the  extent  of  the  dulness  downwards.  If  the  abscess  contain  gas, 
the  diagnosis  is  easier  on  both  sides,  but  on  the  left  side  the  stomach 
note  must  not  be  mistaken  for  an  indication  of  gas.  The  percussion 
over  the  supposed  air  cavity  must  always  be  compared  with  the  true 
stomach  note. 

The  most  certain  method  of  diagnosis  in  both  groups  of  cases 
is  by  means  of  exploratory  puncture.  But  we  must  not  resort  to 
it  until  all  other  diagnostic  methods  have  been  exhausted,  and  we 
are  prepared  to  proceed  immediately  to  radical  operation.  Otherwise, 
by  puncturing  through  the  pleural  space  we  run  the  risk  of  making 
a  way  for  the  pus,  which  is  under  pressure  in  the  sub-phrenic  abscess, 
to  open  into  the  pleura. 

If  the  exploratory  puncture  shows  that  pus  is  present,  we  can 
judge  of  its  origin  by  the  depth  at  which  we  reach  it.  A  depth 
of  several  centimetres  points  to  a  sub-diaphragmatic  collection,  but 
a  superficial  situation  is  no  argument  against  it. 

One  may  be  inclined  to  draw  conclusions  from  the  pressure 
conditions.  Theoretically,  pleural  pus  should  flow  out  during 
expiration,  and  sub-phrenic  pus  during  inspiration.  But  as  a  matter 
of  fact,  adhesions  and  indurations  may  also  put  pleural  pus  under 
pressure  during  inspiration.  The  same  applies  to  the  respiratory  move- 
ments which  the  diaphragm  imparts  to  the  needle  inserted  into  it. 

If  exploratory  puncture  only  reveals  serous  fluid,  this  does  not 
exclude  a  sub-phrenic  abscess.  Indeed,  it  strengthens  our  suspicion, 
and  we  must  explore  at  a  greater  depth.  If  then  we  strike  gas  or 
pus,  our  diagnosis  is  confirmed,  and  the  pleurisy  is  to  be  regarded 
as  a  neighbouring  symptom  dependent  upon  toxic  irritation  of 
the  pleura. 

If  clinical  symptoms,  including  pain  on  local  pressure — a  symptom 
we  have  not  yet  mentioned — definitely  point  to  sub-phrenic  abscess, 
we  must  not  be  content  with  one  exploratory  puncture  which  gives 
a  negative  result.  We  must  insert  the  needle  at  one  or  several  sittings 
in  different  directions,  and  thus  we  may  at  times  be  able  to  discover 
localized  abscesses,  or  those  difficult  of  access. 

I  have,  more  than  once,  seen  the  gradual  disappearance  of  a 
sub-phrenic  abscess  which  has  been  diagnosed  from  the  clinical 
symptoms,  but  which  the  needle  has  failed  to  find.  There  can  be 
no  doubt  that  the  peritoneum  has  the  power  of  absorbing  pus  from 
this  situation  also.  But  if  the  puncture  has  revealed  the  abscess,  we 
must  not  content  ourselves  with  this  possibility,  but  it  is  our  duty 
to  open  it. 


TUBERCULAF-J    PERITONITIS  281 

CHAPTER  XXXVIII. 
TUBERCULAR  PERITONITIS. 

The  surgeon  has  a  double  interest  in  tubercular  peritonitis,  which 
was  for  so  long  considered  an  exclusively  medical  condition.  In  the 
tirst  place,  it  demands  his  consideration  in  the  differentiation  of  the 
various  diseases  of  the  abdomen,  and,  secondly,  he  is  often  called 
upon  to  pave  the  way  for  its  cure,  by  the  performance  of  laparotomy. 
Our  knowledge  of  the  disease  has  been  derived,  to  a  considerable 
extent,  from  its  surgery,  which  has  also  greatly  increased  its  general 
interest. 

Every  student  knows  from  his  reading  of  special  pathology  that 
tuberculous  peritonitis  is  of  frequent  occurrence,  that  it  may  exist  in 
a  serous,  nodular  or  adhesive  form,  and  that  these  forms  may  all  be 
combined  in  one  case.  Nevertheless,  it  is  a  most  common  occurrence 
in  practice  to  overlook  these  cases  in  their  early  stages.  This  is 
accounted  for,  to  a  considerable  extent,  by  their  protean  nature. 
Many  cases  are  diagnosed  as  "nervous  dyspepsia,"  chronic,  gastric, 
or  intestinal  catarrh,  &c.,  when  a  careful  examination  of  the  abdomen 
would  already  reveal  an  effusion,  or  palpable  tubercular  masses. 
This  oversight  is  due  to  the  fact  that  in  its  early  stages  the  disease 
has  no  specially  characteristic  symptoms  to  draw  attention  to  its 
existence,  and  it  is  therefore  most  important  to  examine  carefully  and 
repeatedly  patients  who  complain  of  indefinite  discomfort  in  the 
abdomen. 

This  indefinite  discomfort  consists  of  loss  of  appetite,  a  sensation 
of  pressure  in  the  stomach  and  bowels  during  digestion,  irregularity 
of  the  stools,  occasionally  diarrhoea,  attacks  of  colic  and  a  vague 
feeling  of  heaviness  and  soreness  in  the  abdomen  ;  sometimes  also 
dysuria.  If  these  symptoms  have  persisted  for  weeks  or  months, 
anaemia  and  emaciation  supervene,  and  both  patient  and  practitioner 
begin  to  think  of  some  serious  malady.  If  the  patient  is  young,  if  he 
comes  from  a  tubercular  stock  and  has  probably  some  previous 
tubercular  history  himself,  it  requires  no  complicated  association  of 
ideas  to  think  of  tubercular  peritonitis.  But  in  the  absence  of  such 
indications,  even  the  most  experienced  practitioner  may  grope  in  the 
dark,  especially  in  a  patient  over  50  years  of  age. 

After  general  examination,  directed  especially  to  the  lungs  and 
kidneys,  in  addition  to  any  striking  external  signs  of  existing  or  old 
tuberculosis — scars  of  glands,  bone  disease — we  proceed  to  an  investi- 
gation of  the  abdomen.  This  may  be  quite  flat,  and  without  any 
abnormal    dulness.     But    we   are    struck    by   slight   rigidity   of    the 


282       SURGICAL   DISEASES   OF   THE   ABDOMINAL   AND   PELVIC   VISCERA 


abdominal  muscles ;  much  less  than  in  an  early  septic  peritonitis, 
but  still  quite  demonstrable.  Palpation  is  not  really  painful  for  the 
patient,  but  is  unpleasant.  Such  a  condition,  found  at  repeated 
examinations,  ought  to  excite  serious  suspicion.  This  represents  the 
stage  wherein  the    parietal    peritoneum,  which    alone    is    capable    of 

receiving  sensations  of  pain, 
has  become  sensitive  owing  to 
the  implantation  of  tubercles. 
Later  on,  this  sensibility  be- 
comes diminished  by  the  fluid 
effusion  which  lies  as  a  pro- 
tection between  the  intestine 
and  abdominal  wall,  and  by 
adhesions.  This  stage  is  common 
to  all  varieties,  but  its  subse- 
quent course  varies  considerably. 
In  most  cases,  it  is  possible  to 
detect  a  movable  effusion  after 
a  few  weeks  ;  sometimes,  how- 
ever, not  until  after  a  few  months. 
This  effusion  is  not  always  abund- 
ant. If  the  patient  when  viewed 
in  profile  has  an  abdomen  too 
prominent  for  his  figure  (fig.  146), 
if  he  has  shifting  dulness  over 
the  symphysis  —  N.B.,  when  the 
bladder  is  empty  —  and  above 
Poupart's  ligaments,  this  suffices 
to  establish  the  presence  of  effu- 
sion. It  is  not  necessary  to  wait 
until  the  whole  abdomen  fluctu- 
ates and  the  carriage  of  the 
patient  resembles  that  of  a  preg- 
nant woman.  In  other  cases  we 
may  look  in  vain  for  any  sign  of 
j  effusion.  On  the  contrary,  some 
portions  of  the  abdomen  will  be 

Fig.  146. — Tubercular  peritonitis.  Moderately       r    u  +      i        u        i        +i  1  i 

extensive  effusion.  Abnormally  prominent  abdo-       I^lt  tO  be    harder  than  USUal,  and 

men  for  a  man.  to  develop  into  flat,  firm,  cake- 

like masses  or  into  roundish,  and 
somewhat  fixed  nodules,  which  are  neaily  always  painful  on  pressure. 
In  certain  other  cases  the  abdomen  gradually  gets  larger,  without 
effusion  and  without  these  hard  masses,  being  tympanitic  all  over,  but 
remarkably    incompressible    and    tender    throughout.      This    is    the 


TUBERCULAR   PERITOXITIS  283 

adlicsivc  form,  wherein  the  coils  of  intestine  are  glued  together  in 
layers,  by  the  tubercular  process,  thus  hampering  their  free  movement 
and  peristaltic  action. 

This  explains  the  slight  compressibility  of  the  stomach  and  the 
meteorism. 

Among  the  mixed  forms,  it  is  necessary  to  particularize  those 
wherein  there  exist  encysted  effusions  of  fluid,  caused  by  a  combina- 
tion of  adhesive  and  exudative  processes.  These  effusions  are 
generally  situated  in  the  middle  or  lower  abdominal  region,  and 
usually  contain  serous  fluid,  but  sometimes  their  contents  are 
purulent,  or  in  layers  of  a  sero-iibrinous-purulent  fluid.  The 
nodular  form  of  tubercular  peritonitis  is  not  as  a  rule  pure  in 
character,  but  is  combined  with  exudative  or  adhesive  processes, 

Each  of  the  above  described  varieties  has  its  special  difficulties 
of  differential  diagnosis. 

(i)  The  purely  exudative  variety  may  be  confused  with 
cirrhosis  of  the  liver,  especially  if  the  patient  is  elderly  and  previous 
addiction  to  alcohol  cannot  be  excluded.  In  such  a  case,  an 
evening  rise  in  temperature  points  to  tubercle  ;  but  a  normal 
temperature  is  no  argument  against  it. 

It  should  be  emphasized  here,  that  it  is  not  enough  to  take 
the  temperature  now  and  again,  at  the  doctor's  visits.  In  all 
cases  wherein  tubercle  is  in  question  it  must  be  recorded  regularly 
for  weeks,  at  least  morning  and  evening.  In  tubercular  peritonitis, 
as  in  other  tubercular  processes,  periods  of  normal  temperature 
may  alternate  with  periods  of  a  slight  rise,  or  definitely  high 
temperature. 

A  firm  consistence  of  the  liver,  if  it  be  palpable,  and  pronounced 
enlargement  of  the  spleen,  are  points  in  favour  of  cirrhosis  of  the 
liver,  whereas  tenderness  on  slight  pressure  and  spontaneous  pains 
are  in  favour  of  tubercle. 

The  difficulty  in  differential  diagnosis  is  illustrated  by  the  circum- 
stance that  tubercular  peritonitis  may  lead  to  cirrhotic  changes  in  the 
liver,  and  that  some  of  the  effusion  may  be  due  to  circulatory  distur- 
bances in  the  region  of  the  portal  vein. 

Peritoneal  tuberculosis  may  be  confused  with  cJiylous  ascites,  more 
especially  as  the  latter  comes  on  as  the  result  of  tubercular  swelling 
of  the  retro-peritoneal  glands.  It  is,  however,  distinguished  by  the 
remarkably  rapid  onset  of  debility  and  the  great  enlargement  of  the 
abdomen,  which  becomes  distended  to  an  extent  which  is,  at  any 
rate,  unusual  in  tubercular  peritonitis.  A  definite  diagnosis  can  only 
be  obtained  after  exploratory  puncture,  which  we  will  discuss 
later  on. 

Chronic  serous  peritonitis  of  the  older  authors  does  not  enter  into 
the  problems  of  diagnosis.     This   term    really  mcludes    tuberculosis, 

19 


284      SURGICAL   DISEASES   OF   THE   ABDOMINAL   AND   PELVIC   VISCERA 

miliaiy  carcinoma  or  sarcoma,  and  endothelioma  of  the  peri- 
toneum. The  exceptions  are  exceedingly  rare;  they  cannot  be 
diagnosed  even  when  the  abdomen  is  opened,  and  can  only  be 
detected  by  histological  or  bacteriological  examination. 

(2)  The  considerations  in  regard  to  the  nodular  form  are  entirely 
different.  In  these  cases,  the  diagnosis  lies  between  tuberculosis  and 
new  growth.  To  a  certain  extent,  we  should  be  influenced  by  the 
age  of  the  patient ;  at  any  rate  below  30  the  chances  are  in  favour 
of  tubercle,  but  discretion  must  be  exercised.  After  40,  the  age 
factor  has  very  little  weight  in  diagnosis. 

For  instance,  a  female,  aged  60,  was  referred  to  me  because  of 
numerous  abdominal  tumours,  which  at. first  sight  suggested  cancer. 
Careful  examination,  however,  showed  that  the  case  was  one  of 
nodular  tubercular  peritonitis,  and  this  Avas  confirmed  by  operation. 
On  the  other  hand,  cancer  of  the  ovary  is  no  rarity  among  women 
of  30  to  35  years  of  age. 

More  importance  must  be  attached  to  any  kind  of  rise  in 
temperature,  but  here  also  caution  is  necessary. 

A  young  woman,  after  undergoing  treatment  in  a  sanatorium  for 
pulmonary  disease,  came  under  surgical  treatment  for  a  small,  mov- 
able tumour  in  the  right  lower  abdominal  region.  The  structure  w^as 
hardly  as  big  as  a  walnut,  but  close  to  it  were  some  deep,  but  less 
movable  lumps,  and  a  little  free  effusion  was  present.  There  were  no 
signs  of  narrowing  of  the  intestine.  The  elevations  of  the  tempera- 
ture w^ere  very  striking  :  they  often  exceeded  I02°F„,  and  could  not  be 
explained  by  the  condition  of  the  lungs,  in  which  there  w^as  nothing 
abnormal.  Everything  pointed  to  tubercle,  but  the  striking  mobility 
of  the  small  tumour  made  one  think  of  the  possibility  of  carcinoma, 
because  tubercular  masses  soon  lose  their  mobility.  Operation 
revealed  a  small  carcinoma  of  the  small  intestine  which  had  pro- 
duced no  constriction,  and  early  infection  of  the  peritoneum  with 
carcinomatous  infiltration  of  the  retro-peritoneal  glands. 

In  women  the  clearest  information  can  be  obtained  by  examining 
the  uterine  appendages,  which  constitute  the  most  frequent  starting 
point  both  of  tubercle  and  cancer  of  peritoneum.  Bilateral,  sausage- 
shaped,  or  nodular  induration  of  the  tubes  points  to  tubercle  or 
chronic  gonorrhoea  ;  the  presence  of  a  nodular  tumour  in  the  vicinity 
of  one  ovary  points  to  cancer.  But  primary  ovarian  cancer  is 
sometimes  so  small  that  it  can  hardly  be  detected. 

The  demonstration  of  nodules  in  Douglas's  pouch  may  signify 
either  tubercle  or  cancer.  The  presence  of  tubercle  in  the  urinary 
tract  is  more  decisive,  because  it  is  a  very  frequent  accompaniment 
of  tubercular  peritonitis. 

(3)  The  purely  adhesive  forms,  as  far  as  they  cause  symptoms, 
are  most  likely  to  be  mistaken  for  intestinal  obstruction,  due  to 
chronic  adhesions,  which  are  the  result  of  some  previous  inflamma- 
tory  process  within    the   abdomen.      But    their    chronic    course,  the 


-  TUBERCULAR    PERITOXITIS  285 

diffuse  character  of  their  symptoms,  and  the  tenderness  on   pressure 
constitute  vakiable  evidence  for  tubercle. 

(4)  The  differential  diagnosis  of  encysted  tubercular  effusions 
is  of  great  importance,  although  not  always  easy.  In  these  cases  the 
question  arises  whether  we  are  not  dealing  with  a  cystic  tinnour — i.e., 
an  ovarian,  omental,  or  mesenteric  cyst.  This  question  is  all  the 
more  pressing,  because  these  encysted  tubercular  effusions  often 
occupy  the  median  line,  as  we  have  already  seen.  The  character 
of  the  dulness  is  the  same  in  both — i.e.,  dulness  in  the  middle  of 
abdomen  with  a  normal  intestinal  note  above  and  at  the  sides ; 
whereas  in  a  recent  effusion  the  conditions  are  just  the  reverse.  The 
decision  depends  upon  the  mobility  of  the  structure  as  a  whole,  and 
it  will  often  be  necessary  to  give  an  anaesthetic  in  order  to  abolish 
the  abdominal  rigidity  before  determining  this.  A  cyst,  even  if 
extensively  adherent,  is  usually  somewhat  movable,  and  gives  the 
impression  of  a  round  tumour,  independent  of  the  abdominal  wall, 
if  the  latter  is  completely  relaxed.  An  encysted  effusion,  on  the  other 
hand,  is  hardly  movable  at  all ;  and  even  if  it  appears  to  be  round 
in  shape,  is  usually  connected  to  the  anterior  abdominal  wall. 

The  case  of  a  little  girl,  who  was  suspected  of  having  an  encysted 
tubercular  effusion,  occurs  to  me.  Careful  examination  showed  that 
the  structure  was  movable,  though  only  slightly  so,  and  therefore  the 
diagnosis  seemed  to  be  a  cyst,  whose  situation  suggested  an  origin 
either  from  the  omentum  or  mesentery.  Operation  proved  that  it  was 
a  large  serous  omental  cyst,  and  its  histological  examination  excluded 
the  possibility  of  its  tubercular  origin. 

Finally,  it  is  necessary  to  refer  to  the  confusion  of  a  tubercular 
exudation  with  a  sacculated  pneiunococcic  peritonitis.  A  pneumo- 
coccic  exudation  causes  so  little  surrounding  inflammatory  reaction 
that  it  is  very  often  mistaken  for  tubercular  peritonitis  (tig.  142), 
unless  the  practitioner  has  followed  the  whole  course  of  the  case 
from  the  beginning.  If  the  patient  is  a  young  girl,  and  there  is 
a  history  of  a  sudden  illness,  starting  with  high  fever,  rigors,  vomiting 
and  diarrhoea  which  subsided  into  a  quieter  stage  after  one  to  two 
weeks,  we  may  be  quite  sure  that  the  case  is  one  of  tubercular 
peritonitis. 

The  "  regular"  course  of  tubercular  peritonitis,  as  described  above, 
is  often  interrupted  by  intervals  which  are  caused  by  partial  or  complete 
intestinal  obstruction,  due  to  kinking  of  the  bowel,  by  localized 
adhesions,  or  omental  bands.  We  will  again  meet  with  these  con- 
ditions, in  discussing  intestinal  obstruction. 

Our  task  is  not  exhausted  with  the  mere  diagnosis  of  tubercular 
peritonitis.  We  must  endeavour  to  determine  its  point  of  origin,  at 
any  icite,  as  far  as  it  concerns  treatment.  We  have  already  mentioned 
tubercle  of  the  tubes.     A  second  source  of  origin  is  to  be  found  in  the 


286      SURGICAL   DISEASES    OF  THE   ABDOMINAL   AND    PELVIC   VISCERA 

intestine.  We  do  not  recognize  intestinal  tuberculosis  so  much  by- 
palpation  as  by  functional  disturbance,  because  the  results  of  palpation 
in  extensive  tubercular  peritonitis  are  very  equivocal.  Tuberculosis 
of  the  small  intestine  often  leads  to  stenosis  ;  ileo-caecal  tuberculosis 
nearly  always  does  so.  We  therefore  witness  the  picture  of  chronic 
intestinal  obstruction,  the  description  of  which  will  be  found  in  the 
appropriate  chapter. 

It  must  not  be  assumed  that  the  association  of  tuberculosis  of  the 
mucous  membrane  of  the  bowel  with  extensive  tubercular  peritonitis  is 
the  regular  thing.  On  the  contrary  we  often  see  intestinal  tuberculosis 
combined  with  very  localized  tubercular  changes  in  the  peritoneum. 
The  production  of  a  widespread  tubercular  peritonitis  probably  requires 
the  simultaneous  invasion  of  a  large  amount  of  infective  material, 
such  as  is  most  likely  to  be  derived  from  a  tuberculous  tube  or  a 
softened  mesenteric  gland.  If  a  tubercular  ulcer  of  the  intestine  leads 
to  tubercular  peritonitis,  there  is  usually  an  intermediate  stage  provided 
by  tubercular  glands.  Tubercular  peritonitis  often  follows  a  pleurisy  of 
similar  origin.     As  is  well  known,  the  diaphragm  is  not  bacteria  proof. 

Exploratory  puncture  is  not  always  harmless  in  cases  of  tubercular 
peritonitis,  and,  therefore,  should  only  be  performed  when  the  indica- 
tions are  definite  ;  for  instance  in  the  ascitic  form,  if  the  differential 
diagnosis  between  it,  cirrhosis  of  the  liver  and  chylous  ascites  cannot 
otherwise  be  made. 

It  only  now  remains  to  consider  how  an  accurate  diagnosis  helps  us 
in  framing  indications  for  prognosis  and  treatment.  That  tubercular 
peritonitis,  even  in  the  anatomical  sense,  is  susceptible  of  cure  has  been 
proved  by  surgical  experience.  Recent  statistics  show  that  one-third 
of  the  cases  recover,  even  without  operation.  It  has  been  suggested 
that  the  numerous  cases  which  have  been  treated  medically  without 
any  benefit,  and  then  have  promptly  recovered  after  operation,  were 
really  on  the  point  of  spontaneous  recovery.  But  this  only  begs  the 
question  and  does  not  explain  it.  In  the  early  stage,  operation  should 
only  be  undertaken  to  remove  the  primary  disease,  e.g.,  a.  tuberculous 
tube.  Otherwise  we  must  continue  for  weeks,  or  if  the  patient's 
social  circumstances  permit,  for  months,  with  dietetic  and  climatic 
treatment,  sunshine  and  X-rays.  Sunshine  seems  to  be  the  most 
important  of  these  methods.  If  this  is  meffectual,  operation  is 
indicated,  unless  there  are  other  foci  of  tuberculosis  which  are 
threatening  the  patient's  life.  The  recognition  of  the  variety  of 
tubercular  peritonitis  is  important,  therefore,  not  merely  as  a  general 
indication,  but  as  an  element  in  the  prognosis.  This  is  very  much 
more  favourable  in  the  ascitic  form  than  in  the  other  varieties.  The 
prospects  are  rather  unfavourable  if  the  nodules  undergo  caseation  or 
suppurative  softening.  But  we  should  not  abandon  operation  in 
these  cases,  because  every  now  and  again  an  unexpected  and  per- 
manent success  compensates  for  man}^  failures.  It  is  only  in  the 
purely  adhesive  form  that  operation  is  hopeless. 


DIAGNOSIS    OF   ABDOMINAL   SWELLINGS    IN    GENERAL  287 


CHAPTER    XXXIX. 

DIAGNOSIS   OF   ABDOMINAL    SWELLINGS 
IN    GENERAL. 

The  abdomen  is  the  seat  of  various  false  tumours.  Everyone 
knows  how  easily  the  ahdoininal  aorta  is  felt  in  thin  subjects,  and  its 
pseudonym  "  student's  aneurism  "  is  fully  deserved.  More  than  one 
practitioner,  even,  have  been  deceived  by  it.  On  the  other  hand, 
a  genuine  aneurism  may  be  mistaken  for  a  new  growth.  If  the 
abdominal  wall  is  not  very  yielding,  so  that  the  structure  cannot  be 
adequately  grasped,  it  may  be  impossible  to  distinguish  between  a 
heaving  and  an  expansile  impulse.  The  phantom  tumour  caused  by 
contraction  of  the  upper  part  of  the  abdominal  rectus  is  also  well 
known.  Error  can  generally  be  avoided  by  palpating  the  opposite 
side.  If  the  pylorus  is  sensitive  to  pressure,  the  right  rectus  contracts 
when  it  is  palpated,  whereas  on  the  left  side  the  muscle  remains  quite 
lax.  If  the  patient  is  directed  to  sit  up  without  the  help  of  his  arms,  it 
can  be  readily  felt  that  the  doubtful  swelling  is  the  muscle  itself.  The 
pancreas  may  constitute  another  false  tumour.  In  very  emaciated 
persons  its  head  may  be  distinctly  felt  to  the  right  of  the  spinal 
column,  and  it  may  easily  be  mistaken  for  a  thickened  pylorus.  Dis- 
tension of  the  stomach,  however,  causes  the  pancreas  to  recede, 
whereas  a  pyloric  tumour  would  become  more  superficial.  In  persons 
with  relaxed  or  thin  abdominal  integuments,  it  is  quite  possible  under 
favourable  conditions  to  feel  parts  of  the  normal  stomach — the  pylorus 
and  greater  curvature.  Fcecal  accunndations  should  rarely  lead  to 
mistakes,  if  one  remembers  the  course  of  the  large  intestine,  and  if  the 
patient  has  been  purged  before  the  examination.  It  can  happen  but 
rarely,  that  a  mass  of  faeces  in  the  caecum  will  resist  for  many  days 
attempts  at  purgation,  although  I  have  had  Such  a  case  in  an  old 
woman. 

In  "  Hirschsprung's  disease"  the  sluggishness  of  the  bowels  may 
permit  of  the  accumulation  of  faeces  to  the  extent  that  a  sarcoma 
is  diagnosed. 

Sometimes  intussusception  imitates  a  tumour,  apart  from  the  cases 
wherein  a  new  growth — e.g.,  a  polypus — has  caused  the  intussusception. 
The  typical  tumour  of  intussusception  is  recognized  by  its  cylindrical 
shape  and  its  position  quite  close  to  the  spinal  column. 

Tumours  and  swellings  of  the  abdominal  wall,  described  in  a 
separate  chapter,  must  not  be  confused  with  abdominal  tumours. 

Finally,  it  must  be  remembered  that  inflammatory  changes  may 
resemble  abdominal  tumours.  This  applies  to  inflammatory  swellings 
of  the  omentum,  which  develop  as  a  result  of  an  omental  secretion, 


288       SURGICAL   DISEASES    OF   THE    ABDOMINAL   AND    PELVIC   VISCERA 

that  is  not  quite  aseptic,  as  first  shown  by  Braun.  A  clue  is  afforded 
by  the  history  and  the  pyrexia. 

An  ordinary  appendicitis  may  sometimes  develop  into  a  hard 
immovable  lump,  as  large  as  a  fist  or  larger,  filling  up  the  pelvic 
fossa,  and  requiring  weeks  or  months  for  its  absorption.  This 
phenomenon  is  due  either  to  some  special  peculiarity  of  the 
organisms  causing  the  inflammation,  or  to  some  abnormally  sluggish 
reaction  of  the  system. 

In  a  case  of  this  kind,  in  an  elderly  man,  even  at  the  operation 
I  made  a  provisional  diagnosis  of  cancer  of  the  caecum,  and  per- 
formed an  intestinal  anastamosis.  A  few  months  later  the  whole 
resistance  had  disappeared,  and  the  patient  enjoyed  good  health  for 
seven  years  after  the  operation. 

Such  cases  are  very  similar  to  the  "  phlegmon  ligneux "  of  the 
neck.  If  we  consider  the  extent  and  duration  of  the  induration  which 
may  be  caused  by  a  small  perimetritic  abscess,  it  is  not  at  all 
surprising  that   a   similar  result   may   ensue   from  appendicitis. 

Actinomycosis  occasionally  causes  a  movable  swelling  in  the  ileo- 
caecal  region,  but,  in  contrast  to  cancer,  it  does  not  usually  lead  to 
symptoms  of  obstruction. 

If  a  genuine — or  false — abdominal  tumour  is  definitely  movable, 
its  pedicle  aft'ords  the  best  indication  of  its  origin.  But  as  this 
pedicle  cannot  always  be  felt,  we  can  draw  some  conclusion  as  to 
its  origin  from  the  segment  of  the  circle  which  can  be  described  by 
the  tumour,  as  pointed  out  by  Pagenstecher.  This  task  will  be 
facilitated  by  marking  the  segment  of  the  circle  on  the  abdominal 
wall.  For  instance,  if  the  case  is  one  of  movable  swelling  of  the 
gall-bladder,  wherein  the  tumour  can  be  displaced  even  as  far  as 
the  left  hypochondrium,  the  centre  of  the  segment  of  the  circle 
described  by  the  tumour  will  always  be  at  the  normal  site  of  attach- 
ment of  the  gall-bladder.  The  curve  will  be  concave  upwards  in 
contrast  to  the  curve  of  a  pedunculated  ovarian  cyst,  which  is  concave 
downwards,  with  a  centre  which  is  either  in  the  mid-line  or  more  or 
less  to  one  side.  In  a  similar  manner,  it  is  possible  to  ascertain  the 
origin   of  a  swelling  which   consists   of  a  floating  kidney. 

An  organ  which  under  normal  conditions  is  only  slightly 
movable,  may  be  susceptible  of  considerable  displacement  when  it 
is  the  seat  of  a  tumour,  especially  the  pylorus.  For  instance, 
I  found  a  carcinoma  of  the  lesser  curvature,  the  size  of  a  large  fist, 
situated  at  the  anterior  superior  spine  of  the  left  ilium,  in  a  young 
girl ;  the  tumour  could  be  dragged  about,  almost  all  over  the 
abdomen   (see  under  Cancer  of  the   Stomach). 

Tumour  formation  in  an  organ  which  is  congenitally  displaced 
may  render  the  diagnosis  difficult.  This  applies  particularly  to  the 
kidneys,  which  may  be  found  lying  transversely  in  front  of  the  spine, 
or  more  laterally  at  the  inlet  of  the  true  pelvis. 

It  has  occasionally  been  noted  that  an  ovarian  cyst  may  become 


DIAGXOSIS   OF   ABDOMINAL   SWELLINGS   IN   GENERAL  2S9 

free  and  take  up  its  quarters  elsewhere.  This  of  course  causes  an 
insoluble  problem  in  diagnosis,  before  the  abdomen  is  opened.  On 
one  occasion,  I  found  a  left  ovarian  dermoid  engrafted  on  the  hepatic 
flexure  of  the  colon.  The  remains  of  the  tube  were  still  attached  to 
the  left  side  of  the  uterus. 

If  a  swelling  is  remarkably  movable,  but  no  indication  is  afforded 
by  its  pedicle  or  by  the  curve  described  by  its  movement,  we  should 
think  of  a  tumour  of  the  small  intesline,  niesenlery  or  ouietifinn,  if  it  is 
situated  in  the  middle  of  the  abdomen.  The  first  is  the  most  probable 
if  the  tumour  is  hard  or  uneven  ;  the  other  two  if  it  is  roundish  and 
elastic  in  consistence. 

The  determination  of  the  point  of  origin  is  easier  if  the  tumour  is 
less  movable  and  not  loo  large,  because  the  number  of  organs  with 
which  it  might  be  connected  are  more  limited.  But  even  then,  the 
diagnostic  problem  may  be  very  difficult,  as  for  instance  the  differen- 
tial diagnosis  between  cancer  of  the  duodenum  and  of  the  pancreas, 
enlarged  gall-bladder  and  a  commencing  hydronephrosis,  cancer  of 
the  intestine  and  a  displaced  kidney  which  has  become  fixed,  &c.  A 
correct  diagnosis  can  only  be  formed  by  taking  into  consideration  at 
the  same  time  the  history,  the  functional  disturbance,  the  condition 
found  on  palpation,  and  a  skiagram. 

Tumours  which  occupy  the  ivJiole  or  almost  the  whole  of  the 
abdominal  cavity  are  particularly  difficult  to  diagnose.  If  they  are 
hard,  they  are  essentially  fibro-niyoinala  of  the  nlenis,  rarely  ftbro- 
sarcoinala  of  the  ovary  ;  in  children  they  are  usually  enormous 
sarcoinala  or  mixed  Uunonrs  of  the  kidneys.  Bimanual  gynaecological 
examination,  and  if  necessary  the  sounding  of  the  uterus,  afford  a 
conclusive  decision.  A  sarcoma  of  the  kidney  is  recognized  by  its 
somewhat  lateral  position,  if  it  has  become  very  extensive,  and  by  the 
fact  that  it  reaches  up  into  the  hypochondrium.  Tumours  of  the  fatty 
capsule  of  the  kidney,  just  referred  to,  do  not  adhere  to  any  rule. 

If  the  tumour  is  softly  elastic,  or  fluctuating  and  therefore  probably 
a  cyst,  it  is  necessary  to  distinguish  between  ovarian  cyst  and  hydro- 
nephrosis. The  former  should  be  diagnosed  if  its  consistence  is 
unequal,  being  imeven  and  hard  in  some  places,  soft  or  tensely  elastic 
in  others.  The  ditficulty  in  diagnosis  really  begins  when  the  cystic 
tumours  are  uniform. 

An  ovarian  tumour  of  moderate  size  can  be  best  defined  at  its 
superior  border,  a  hydronephrosis  at  its  lower  border.  In  more 
advanced  stages,  external  examination  may  be  quite  inconclusive.  If 
both  ovaries  can  be  felt  on  bimanual  examination,  the  matter  is 
decided,  because  parovarian  cysts  are  not  in  question  where  large 
tumours  are  concerned.  But  if,  as  usually  happens,  the  two  ovaries 
cannot  be  felt,  the  large  intestine  should  be  distended  to  see  whether 
the  bowel  lies  to  the  outer  side  of  and  above  the  tumour,  or  to  its 


290      SURGICAL   DISEASES   OF   THE   ABDOMINAL   AND   PELVIC   VISCERA 

inner  side  and  beneath  it.  In  the  latter  case  it  is  probably  a  renal 
tumour  ;  in  the  former,  probably  an  ovarian  tumour.  We  say  ''prob- 
ably," because  we  have  also  seen  the  large  intestine  running  above  and 
to  the  outer  side  of  a  renal  tumour.  But  if  this  proceeding  leads  to 
no  definite  conclusion,  we  are  thrown  back  on  a  consideration  of 
the  previous  history.  In  the  case  of  hydronephrosis  there  will  prob- 
ably have  been  attacks  of  renal  colic  with  sudden  and  profuse 
micturition  of  clear  or  blood-stained  urine.  The '  patient  will  also 
have  noticed  that  the  tumour  which  before  had  been  situated  high  up 
has  now  gradually  become  lower.  An  ovarian  tumour,  on  the  other 
hand,  is  practically  painless,  unless  subjected  to  torsion  occasionally, 
and  grows  from  below  upwards.  Finally,  a  decisive  conclusion  may 
be  arrived  at  by  cystoscopy.  If  urine  escapes  from  one  ureter  only, 
we  have  every  reason  for  assuming  that  there  is  a  closed  hydro- 
nephrosis on  the  other  side.  If  both  ureters  are  functional  we  must 
exclude  hydronephrosis. 

If  the  tumour  does  not  fit  in  any  of  these  categories,  we  should 
think  of  one  of  the  rare  mesenteric  or  omental  cysts  (the  latter,  as 
experience  shows,  especially  in  girls  under  10),  or  an  encapsnled 
tubercular  peritonitis,  if  the  structure  seems  to  be  less  movable  and 
less,  well  defined  than  a  genuine  cyst. 

The  rare  condition  of  cystoma  of  the  uterus  is  very  apt  to  cause 
error.  In  one  such  case,  the  tumour  filled  up  both  hypochondria, 
although  the  cervix  was  prolapsed  between  the  labia. 

We  must  also  think  of  the  pregnant  uterus  which  has  sometimes 
been  subjected  to  the  surgeon's  knife,  to  the  silent  but  malicious 
satisfaction  of  the  accoucheur.  It  is  therefore  by  no  means  super- 
fluous to  examine  the  breasts  in  doubtful  cases,  and  also  to  employ 
the  stethoscope.  It  is  of  course  well  known  that  too  much  reliance 
cannot  be  placed  on  the  history,  in  these  circumstances.  If  in  a 
case  of  suspected  pregnancy  the  size  of  the  uterus  is  too  large  for  its 
estimated  duration,  and  if  no  foetal  parts  are  felt,  we  should  think  of 
a  hydatidiform  mole.  If,  in  a  case  of  suspected  pregnancy,  a  slightly 
movable  or  a  definitely  movable  tumour  is  found  at  the  side  of  a 
somewhat  enlarged  and  soft  uterus,  we  should  diagnose  an  extra- 
uterine gestation. 

Every  tumour  raises  the  question  of  innocence  or  nnah'gnancy ; 
a  question  which  we  can  very  often  answer,  even  if  the  origin  of  the 
tumour  is  not  clear.  Three  signs  indicate  malignancy  :  (i)  Rapid 
growth,  and  early  emaciation  of  the  patient  ;  (2),  the  presence  of  free 
fluid  in  the  abdominal  cavity ;  and  (3)  multiplicity  of  the  new  growth. 

To  demonstrate  a  small  amount  of  effusion,  it  is  necessary  to 
percuss  as  gently  as  possible,  with  the  patient  on  the  back  and  on  the 
sides. 

If  the  onset  of  effusion  has  been  preceded  by  an  exacerbation  of 
acute  peritoneal  symptoms,  we  should  always  think  of  the  possibility 


SURGICAL   DISEASES   OF   THE   STOMACH  291 

of  torsion  of  an  innocent  ovarian  tumour.  Multiplicity  of  the 
tumours  indicates  either  malignancy  or  tubercle.  We  have  already 
discussed  their  differential  diagnosis. 

As  in  the  case  of  other  abdominal  diseases  we  have  purposely 
refrained  from  mentioning  exploratory  puncture.  Its  value  is  still 
always  over-estimated,  its  disadvantages  under-estimated.  Puncture  of 
a  solid  tumour  is  harmless,  unless  the  bowel  is  perforated  by  too 
powerful  a  needle,  but  it  is  quite  useless.  If  we  succeed  in  punctur- 
ing a  cyst  with  an  adequately  strong  needle,  we  must  inevitably 
permit  the  escape  of  some  of  the  contents  of  the  cyst  into  the  abdom- 
inal cavity.  This  may  be  a  matter  of  indifference  if  the  swelling  is 
innocent,  but  it  is  most  undesirable  in  cases  of  cancer,  hydatid  or 
suppurating  cyst.  Thus  I  w^as  once  consulted  in  the  case  of  a  young 
girl  who  developed  acute  peritonitis  as  a  consequence  of  exploratory 
puncture  of  a  cystic  abdominal  swelling.  Operation  was  performed 
immediately,  and  it  revealed  a  suppurating  ovarian  cyst  in  which  the 
puncture  was  still  visible  as  the  starting  point  of  the  suppurative  peri- 
tonitis. As  every  ovarian  cyst,  and  every  tumour  whose  differential 
diagnosis  is  doubtful  should  be  operated  on,  and  as  exploratory 
puncture  so  often  leaves  us  in  the  lurch,  this  procedure  is  limited  in 
practical  value  to  the  information  which  it  may  give  as  to  the  aseptic 
or  purulent  condition  of  the  contents  of  the  cyst.  But,  as  just  stated, 
puncture  is  least  permissible  if  there  be  any  suspicion  of  suppuration. 
If,  how^ever,  we  consider  puncture  to  be  indispensable,  it  should  not  be 
done  until  everything  is  in  readiness  for  operation,  or  better  still  until 
after  the  abdomen  has  been  opened  and  the  cyst  exposed.  We  can 
then,  at  any  rate,  prevent  the  unnoticed  entrance  of  pus  into  the 
abdominal  cavity. 


CHAPTER  XL. 

SURGICAL  DISEASES  OF  THE  STOMACH. 

If  this  heading  should  be  understood  to  include  all  diseases  of  the 
stomach  which  have  been  treated  surgically,  it  would  be  necessary 
to  detail  the  diagnosis  of  every  chronic  gastric  disease.  There  are 
very  few^  diseases  of  the  stomach  upon  which  the  surgeon  has  not 
operated,  some  would  say,  out  of  pure  pruritus  operandi  ;  others, 
because  of  the  failure  of  medical  treatment.  Although  the  indica- 
tions for  a  few  of  the  diseases  are  still  uncertain,  the  main  lines  of 
most  of  them  are  well  defined  and  recognized  alike  by  surgeon  and 
physician.  To  these  mainly  we  will  devote  attention,  and  only  touch 
incidentally  upon  ground  which  is  still  contested. 


292       SURGICAL   DISEASES   OF   THE   ABDOMINAL   AND    PELVIC   VISCERA 

Gastric  diagnosis,  as  already  mentioned,  has  made  great  advances 
within  the  last  few  years.  Thanks  to  the  labours  of  Rieder,  the 
skiagram  has  enabled  us  to  complete  our  diagnoses  directly  by  the 
sense  of  sight,  instead  of  relying  upon  indirect  conclusions,  as 
hitherto.  X-ray  examination  of  the  stomach  has  its  own  sources  of 
error,  however,  just  as  every  method  of  diagnosis.  A  diagnosis 
should,  therefore,  not  be  based  exclusively  on  a  skiagram,  which  should 
rather  be  used  as  a  supplement  to  other  methods. 

A  knowledge  of  the  technique  is  indispensable,  in  order  to  under- 
stand the  subsequent  remarks. 

The  patient  is  given  a  contrast-forming  meal,  on  an  empty 
stomach.  It  consists  of  40  grm,  of  carbonate  of  bismuth  or  80  grm. 
of  sulphate  of  barium,  with  400  grm.  of  some  carboh\'drate  porridge 
(in  cases  of  dilatation,  600  grm.).  A  skiagram  is  taken  immediately 
in  the  abdominal  and  in  the  erect  position.  If  a  well  filled  pars 
pylorica  is  not  shown  in  either  of  these  positions,  another  picture 
must  be  taken  with  the  patient  lying  on  the  right  side,  or  with  the 
upper  portion  of  the  body  lowered.  These  pictures  are  indispensable 
because  the  surgeon  must  possess  some  actual  record  on  which  to 
base  his  decision.  He  cannot  rely  upon  the  report  of  a  professional 
radiographer,  who  may  not  have  had  any  surgical  training,  as  to 
what  was  found  on  the  screen,  especiall}^  as  a  screen  examination 
does  not  bring  out  adequately  certain  details,  which  may  sometimes 
be  of  great  importance.  This  applies  particularly  to  cases  wherein 
there  is  a  question,  not  only  of  displacement  of  the  stomach,  but  also 
of  ulcer  or  can.cer.  A  screen  examination  may  be  taken  afterwards, 
and  this  will  enable  a  decision  to  be  made  regarding  the  motor 
functions  of  the  stomach.  It  is  useful  to  get  a  rapid  idea  of  the 
position  of  the  organ  by  means  of  the  screen,  before  plates  are 
taken,  but  this  opportunity  must  not  be  employed  to  study  its  move- 
ments. In  order  to  obtain  a  useful  picture  showing  a  well  filled 
stomach,  the  skiagram  must  be  taken  very  soon  after  the  contrast- 
forming  meal.  Another  skiagram  should  be  taken  in  six  hours,  to 
ascertain  whether  the  stomach  is  empty  or  whether  there  is  retention. 

Before  one  decides  that  the  shape  of  a  stomach  is  pathological, 
it  is  necessary  to  consider  carefully  the  normal  range  of  shape  of 
the  organ.  The  main  varieties  are  illustrated  in  lig.  140,  which 
shows  the  varied  appearances  of  the  stomach,  according  to  its  state 
of  replenishment,  the  position  of  the  bodv,  its  condition  of  motility, 
quite  apart  from  the  influence  exerted  upon  it,  of  external  tumours 
and  growths  of  adjoining  organs. 

The  following  morbid  conditions  come  within  the  province  of 
the  surgeon,  either  entirely  or  partially. 

J.— FOREIGN  BODIES  IX  THE  STOMACH. 

It  is  well  known  that  a  variety  of  articles  may  gain  access 
to  the  stomachs  of  jugglers  and  the  insane.  As  a  rule,  even 
large  objects,  such  as  spoons,  forks,  thermometers,  &c.,  pass  on 
spontaneously,    and    find    their    way    through    the    much     narrower 


SURGICAL    DISEASES    OF    THE    STOMACH 


293 


intestinal  canal,  without  injuring  it.  Surgical  intervention  is,  there- 
fore, but  rarely  required.  Should  it,  however,  be  necessary,  there  is 
no  difficultv  about  the  diagnosis,  and  if  the  history  is  unreliable  a 
skiagram  will  generally  elucidate  any  obscuritv.  It  is  noteworthv  that 
small  foreign  bodies  are   more   likely  to  remain  in  the  stomach  than 


larger   ones 


In  proof  of  this  it  is  onlv  necessary  to  refer  to  the  case  in  which 
the  whole  contents  of  a  nail-box  were  removed  from  the  stomach  : 
over  1,500  nails,  hooks,  tacks,  conglomerated  into  a  mass  weighing 
I  kilo,  certainly  a  record,  even  if  similar  cases  have  been  described 
more  than  once. 

We  may  refer  here  to  concretions  which  develop  in  rare 
instances,  within  the  stomach  itself.  If  we  feel  a  strikingly  movable 
hard  lump  through  the  abdominal  wall,  and  the  patient  is  a  man 
who  has  much  to  do  with  varnish,  and  is  addicted  to  strong  drink, 
we  should  think  of  a  rcsin  stone.  If  such  a  swelling  is  found  in  a 
girl  with  a  long  plait,  who  confesses  to  biting  her  hair  frequentlv,  the 
diagnosis  is  obviously  a  liair  iimioiw. 


i^.— DISPLACEMENTS  OF  THE  STOMACH. 

We  have  referred  to  these,  briefly,  in  discussing  the  abnor- 
malities in  position  of  the  abdominal  viscera.  These  displace- 
ments possess  two  distinctive  signs  :  (i)  The  low  level  of  the  gi"eater 
curvature,  sometimes  even  as  low  as  the  svmphvsis,  easily  demon- 
strable by  ordinary  clinical  methods;  and  (2)  the  low  level  of  the 
pylorus,  which  can  often  be  demonstrated  by  palpation,  but  quite 
easily  by  a  skiagram.  This  does  not,  however,  convert  the  case 
into  a  surgical  one.  A  displaced  stomach  so  often  discharges  its 
functions  quite  normally,  that  we  must  rather  attribute  the  main 
cause  of  symptoms  to  inefficient  muscular  power,  or  t(3  inefficient — 
or  more  correctly  to  purposeless — innervation,  and  not  to  the 
mechanical  circumstance  of  the  gastric  ptosis.  Even  if  it  has  been 
proved  clinically,  and  where  possible  also  by  a  skiagram,  that  the 
stomach  does  not  empty  itself  quickly  enough,  i.e.,  in  the  course 
of  six  hours,  this  is  not  sufficient  to  justify  operation,  if  it  is  the 
only  symptom  present.  In  testing  the  motor  functions  of  the 
stomach,  it  is  most  important  to  limit  the  contrast-forming  meal 
to  a  carbohydrate  porridge,  because  fats  and  albumins  delay  the 
course    of   gastric    digestion. 

It  may  be  mentioned  as  a  curiosity  that  the  stomach  has  often 
been  found  twisted,  with  the  circulatory  disturbances  corresponding 
to  a  volvulus.  This  condition  has  not  yet  been  diagnosed,  but  it 
should  be  suggested  by  fruitless  movements  of  vomiting  and  by 
the  impossibility  of  emptying  the  distended  stomach  by  means  of 
the  tube. 


294       SURGICAL   DISEASES   OF   THE   ABDOMINAL   AND    PELVIC   VISCERA 

C— GASTRIC  ULCER. 

Until  quite  recently,  the  diagnosis  of  gastric  ulcer  was  exclusively 
reserved  for  the  physician.  But  since  surgeons  have  been  operating 
on  certain  cases  of  simple  ulcer,  quite  independently  of  the  complica- 
tions to  be  discussed  subsequently,  and  since  the  X-rays  have  rendered 
it  possible  to  establish  the  diagnosis  with  certainty,  even  in  many 
uncomplicated  ulcers,  the  diagnosis  of  gastric  ulcer  has  been  tending 
to  fall  within  the  provnice  of  the  surgeon. 

(1)  UNCOMPLICATED  GASTRIC  ULCER. 

A  gastric  ulcer  was  "suspected"  formerly — although  its  presence 
could  not  be  proved — if  a  patient  complained,  not  of  vague  indiges- 
tion, but  of  pain  coming  on  at  a  definite  time,  mostly  immediately 
after  meals,  radiating  to  the  back  and  towards  the  left  side.  This 
symptom  was  usually  associated  with  a  pronounced  and  well-defined 
pain  on  pressure  over  a  sharply  localized  area,  generally  in  the  neigh- 
bourhood of  the  smaller  curvature.  Confirmation  of  the  diagnosis 
was  derived  from  the  discovery  of  hyperacidity,  and  it  was  further 
strengthened  if  the  patient  -happened  to  be  a  young  chlorotic  girl. 
But  as  long  as  no  severe  symptoms  came  on,  the  diagnosis  always 
remained  a  "  suspicion."  It  became  more  probable  if  blood  could  be 
detected  microscopically  in  th-e  faeces  after  a  diet  which  contained 
no  meat.  I  say  the  diagnosis  only  became  "  more  probable,"  because 
the  case  might  be  one  of  duodenal  ulcer  or  of  some  ulcerative  condi- 
tion lower  down  in  the  intestine.  Confusion  with  a  duodenal  ulcer 
was  not  a  matter  of  great  importance  because  the  treatment — at  any 
rate,  the  non-operative — was  the  same  in  both,  and  because  a  duodenal 
ulcer  may  often  be  so  close  to  the  pylorus  that  its  site  of  origin  may 
remain  in  doubt,  even  at  the  operation.  The  only  clinical  differences 
consisted  in  the  facts  that  the  seat  of  the  spontaneous  pain  and  the 
pain  on  pressure  in  the  case  of  a  duodenal  ulcer  was  a  little  more  to 
the  right  than  in  gastric  ulcer,  and  that  the  spontaneous  pain  in 
duodenal  ulcer  did  not  supervene  immediately  after  food,  but  was 
delayed  for  a  few  hours,  indeed,  until  the  need  for  another  meal  was 
felt,  constituting  the  so-called  hunger  pain,  often  coming  on  in  the 
course  of  the  night.  These  clinical  differences  still  remain  the  only 
ones  known.  Finally,  it  should  be  mentioned  that  gastric  ulcer  is 
most  frequent  in  the  female  sex,  whereas  duodenal  ulcer  is  practically 
limited  to  males. 

There  can  be  no  doubt  that,  in  this  manner,  ulcers  were  often  dia- 
gnosed which  were  not  present,  and  were  very  frequently  overlooked 
when  they  were  present.  X-rays  have  enabled  us  to  make  great  ad- 
vances in  this  respect,  although  many  a  case  may  still  remain  obscure. 


SURGICAL   DISEASES   OF   THE   STOMACH  295 

The  skiagram  is  of  value  in  the  following  way  : — 

A  superficial  gastric  ulcer  is  not  visible  as  such,  but  if  it  has 
attained  a  depth  of  2  to  3  mm.  it  appears,  under  favourable  conditions, 
as  a  slight,  sharply  defined  bulging  in  the  shadow,  and  thus  looks  like 
a  depression  as  viewed  from  the  stomach.  If  it  has  penetrated  the 
gastric  wall  and  has  extended  to  adjacent  tissue  (retro-peritoneal 
connective  tissue,  liver,  pancreas,  or  spleen),  the  depression  becomes 
quite  like  a  recess — the  so-called  Haudek's  diverticulum,  and  there 
is  often  a  layer  of  gas  over  its  bismuth  shadow  when  the  skiagram 
is  taken  in  the  erect  position.  But  certain  consequences  of  the 
ulcer  are  visible  before  the  ulcer  itself,  the  most  important  of 
these  being  persistent  spasm  of  the  gastric  wall  at  the  level  of  the 
ulcer.  In  the  very  frequent  cases  of  ulcer  of  the  lesser  curvature, 
this  spasm  appears  as  a  sharply  limited  contraction  of  the  greater 
curvature.  Such  muscular  spasms,  always  persistent  in  the  same 
place,  also  occur  in  cases  of  scars  of  old  ulcers  and  in  operation  scars, 
but  probably  do  not  occur  in  normal  stomachs.  Accidental  spastic 
contractions,  which  are  often  met  with  as  momentary  pictiu"es  of  a 
peristaltic  wave,  can  only  be  distinguished  from  persistent  spasm  by 
repeated  examinations. 

Reflex  delay  in  the  emptying  of  the  stomach  is  a  second  indirect 
sign  of  ulcer.  Skiagrams  have  also  shown  that  pyloric  spasm  may 
result  from  an  ulcer  which  is  not  situated  at  the  pylorus,  but  anywhere 
along  the  lesser  curvature. 

Cicatricial  contraction  of  the  stomach  at  the  level  of  the  ulcer,  or 
the  development  of  hour-glass  contraction,  may  be  mentioned  as 
a  third  indirect  sign.     This  matter  will  be  referred  to  later  on. 

How  is  the  so-called  ''  indolent"  nicer  to  be  diagnosed  ?  It  cannot 
be  detected  clinically,  but  can  only  be  determined  at  operation  or  at 
an  autopsy.  All  ulcers  which  penetrate  the  entire  thickness  of  the 
gastric  wall  possess  indolent,  i.e.,  thickened  edges.  The  thickening 
varies  very  much  in  degree  in  accordance  with  the  position  of  the 
ulcer,  its  relations  to  adjacent  organs,  and  probably  also  with  the 
constitutional  reaction  of  the  patient.  An  indolent  ulcer  may  there- 
fore be  diagnosed,  if  we  feel  a  tumour-like  structure,  without  being 
able  to  find  any  diagnostic  signs  of  cancer.  But  an  indolent  condition 
of  the  ulcer  does  not  necessarily  signify  the  presence  of  perigastric 
changes.  An  ulcer  may  cause  perigastritis  long  before  the  "  indolent" 
changes  occur,  and  on  the  other  hand  the  perigastric  changes  asso- 
ciated with  such  an  ulcer  may  develop  so  slowly  that  no  clinical 
manifestations  arise. 

How  does  radiography  help  in  distinguishing  a  gastric  from  a 
duodenal  ulcer  ? 

Principally  by  a  negative  sign.  If  the  clinical  suspicion  of  .an 
ulcer  is  supported  by  the  presence  of  blood  in  the  stools,  but  a  careful 
X-ray  examination  of  the  stomach  fails  to  find  any  abnormality,  we 
are  bound  to  diagnose  a  duodenal  ulcer,  by  exclusion.  Moynihan 
and  Haudek  state  that  this  diagnosis  is  all  the  more  probable  the 
more  rapidly  the    stomach  empties    itself,  because  a  duodenal  ulcer 


296      SURGICAL   DISEASES    GF   THE   ABDGMINAL   AND    PELVIC   VISCERA 

produces  a  reflex  patency  of  the  pylorus,  in  contrast  to  a  gastric 
ulcer.  The  absence  of  any  downward  displacement  of  the  pylorus 
in  a  skiagram  of  the  full  stomach  in  the  erect  position  is  additional 
evidence  of  duodenal  ulcer. 

Positive  changes  in  the  duodenal  shadow  have  not  often  been 
obtained  in  cases  of  ulcer.  They  consist,  either  of  cicatricial  contrac- 
tion of  the  duodenum,  or  of  the  formation  of  recesses  in  this  situation. 
These  changes  are,  however,  very  rare. 

Does  the  skiagram  offer  any  indications  for  surgical  treatment, 
apart  from  the  complications  to  be  discussed  below  ?  This  is  hardly 
to  be  expected ;  the  necessity  for  operation  depends  upon  the  sub- 
jective symptoms,  and  the  possibility  of  their  relief  by  medical 
measures.  It  is  entirely  a  cHnical  matter ;  but  skiagraphy  has 
rendered  it  possible  to  confirm  the  diagnosis,  in  those  cases  wherein 
operation  is  suggested,  with  unquestionable  accuracy. 

(2)  H>EIV10RRHAGE. 

We  learn  from  general  medicine  how  to  recognize  the  gastric 
origin  of  a  haemorrhage,  and  how  to  distinguish  it  from  haemorrhage 
due  to  cirrhosis  of  the  liver.  But  special  reference  should  be  made 
to  hysterical  Jicviiioirliage,  because  this  is  apt  to  be  frequently  repeated, 
and  therefore  to  simulate  just  that  kind  of  gastric  ulcer  which  should 
receive  surgical  treatment. 

Josserand  points  out  that  in  hysterical  vomiting  of  blood  there 
is  much  admixture  with  mucus,  so  that  it  looks  like  fruit  juice,  and 
as  a  rule  it  does  not  coagulate.  Josserand  suggests  that  the  blood 
comes  from  the  oesophagus. 

I  was  once  misled,  in  common  with  the  physician  in  attendance, 
by  such  vomiting  of  blood,  and,  after  considerable  internal  treatment, 
decided  upon  gastro-enterostomy.  The  further  progress  of  the  case 
showed  that  we  had  been  deceived  by  hysteria.  The  comparatively 
trifling  degree  of  anaemia,  by  which  we  were  indeed  struck,  should 
have  made  us  hesitate. 

The  course  to  adopt  in  regard  to  haemorrhages  is  rather  difficult 
to  decide.  The  practitioner  calls  in  the  surgeon  even  when  small 
hzemorrhages  threaten  life  by  their  frequent  repetition,  and  the 
decision  as  to  operation  is  left  to  him.  We  should  advise  non- 
interference in  the  case  of  a  single  severe  haemorrhage  if  this  seems 
to  him  the  preferable  course. 

(3)  PERFORATION. 

The  diagnosis  of  a  perforated  ulcer,  on  the  other  hand,  falls  quite 
within  the  province  of  the  surgeon.  Rapid  reflection  and  immediate 
treatment  are  indispensable.  Cases  operated  on  within  the  first 
twelve  hours  usually  recover  ;  after  the  first  twenty-four  hours  the 
mortality  is  75  per  cent. 


SURGICAL   DISEASES    OF    THE    STOMACH  297 

If  a  person — remarkably  enough  it  generally  happens  in  a  man — 
suddenly  experiences  severe  pain  like  the  thrust  of  a  dagger  in  the 
epigastrium,  followed  by  rigidity  of  the  abdominal  muscles,  local 
pain  on  pressure,  acceleration  of  pulse  and  occasionally  a  rise  in 
temperature,  we  should  think  of  a  perforated  ulcer,  although  the 
patient  may  not  have  manifested  any  signs  of  gastric  ulcer  previously. 
The  perforation  is  often,  but  not  always,  associated  with  collapse, 
from  which  the  patient  may  temporarily  recover  before  the  classical 
symptoms  of  peritonitis  set  in.  In  such  cases,  even  the  delay  of  half 
a  day  ''for  the  purpose  of  better  observation,"  means  to  abandon  the 
patient  to  almost  certain  death.  If  we  first  see  the  case  at  a  later 
stage  there  is  either  general  peritonitis,  the  origin  of  which  cannot 
be  traced,  or  there  may  be  the  condition  termed  by  Lennander 
peripheral  peritonitis.  After  perforation  the  gastric  contents  flow 
towards  the  anterior  surface,  preferably  under  the  liver  towards  the 
right  lumbar  region,  thence  into  the  true  pelvis,  and  the  peritonitis 
eventually  ascends  along  the  left  side,  without  always  affecting  the 
convolutions  of  the  small  intestine,  which  are  covered  by  omentum. 
This  peripheral  form  remains  longer  accessible  to  surgical  treatment 
than  the  central  form.  If  we  find  the  patient,  as  is  usuall}^  the  case 
on  the  second  or  third  day,  in  a  condition  of  cyanosis  with  a 
tympanitic  abdomen,  cold  extremities,  and  a  thread-like  pulse,  it  is 
always  questionable  whether  operation  is  worth  while.  It  may  only 
shorten  the  patient's  life  by  a  few  hours  and  redound  but  little  to 
the  credit  of  our  art. 

The  rare  exceptions,  when  the  perforation  is  minute  and  a  cure 
ensues  without  operation  because  the  stomach  is  empty,  constitute, 
of  course,  no  argument  against  the  above.  I  have  had  this  expe- 
rience in  a  case  where  operation  was  refused.  We  must  not  risk 
the  patient's  life  on   such  an  uncertain  hazard. 

We  must  now  deal  briefly  with  some  details.  In  most  cases  the 
previous  history  permits  of  the  diagnosis  of  gastric  ulcer,  or  at  any  rate 
suggests  it,  but  not  always.  If  premonitory  symptoms  have  preceded 
the  perforation,  the  diagnosis  becomes  much  easier.  But  as  a  rule 
there  are  none.  The  very  suddenness  and  great  violence  of  the  pain 
in  tJie  gastric  region  are,  however,  of  themselves  symptoms  of  the 
greatest  significance,  and  the  patient  is  well  able  to  distinguish  them 
from  ordinary  gastralgia. 

In  certain  cases  the  perforation  is  preceded  by  perigastric 
symptoms.  In  one  of  my  cases  the  patient  neglected  these  warnings, 
so  that  they  proved  of  no  service  to  him.  If  they  occur  in  a  case 
wherein  an  ulcer  has  already  been  diagnosed,  they,  at  any  rate,  give 
due  notice  of  the  possibility  of  the  threatening  danger,  and  if  perfora- 
tion actually  occurs,  operation  can  take  place  all  the  more  readily. 

The  initial  pain   is  never  absent,  but   it  may  be  less  severe  than 


298       SURGICAL   DISEASES    OF   THE   ABDOMINAL   AND    PELVIC   VISCERA 

usual  if  the  perforation  does  not  exceed  a  pin  point  in  size,  as 
sometimes  happens.  The  pain  often  radiates  into  the  back,  especially 
between  the  scapulae,  or  into  the  left  shoulder  and  left  arm,  just  as  the 
pain  of  biliary  disease  radiates  into  the  right  shoulder. 

The  distribution  of  the  pain  which  occurs  later  on,  is  of  less  value 
for  diagnostic  purposes.  It  depends  upon  the  direction  taken  by  the 
flow  of  the  gastric  contents,  and  is  situated  towards  the  lower 
abdominal  region,  either  on  the  right  or  left.  This  explains  why 
perforation  of  the  stomach  has  so  often  been  taken  for  disease  of 
the  female  pelvic  organs.  The  same  applies  to  the  pain  on  pressure. 
I  have  found  this  to  be  most  pronounced,  twenty  hours  after  perfora- 
tion, in  the  left  lower  abdominal  region. 

Pulse,  tenipevattire  3.nd  respiration  behave  as  in  any  other  perforation 
of  a  viscus.  The  pulse  is  slightly  accelerated,  but  may  remain  so  full, 
strong,  and  quiet  for  the  first  few  hours,  probably  through  vagus 
stimulation,  that  the  inexperienced  may  entirely  dispose  of  the  idea 
of  perforation.  A  normal  temperature  does  not  exclude  perforation, 
but,  on  the  other  hand,  a  rise  in  temperature  shows  that  the  case 
is  not  an  ordinarv  stomach  ache.  Respiration  is  hurried,  shallow  and 
thoracic.  It  is  an  error  to  suppose  that  vomiting  does  not  occur  ;  on 
the  contrary  it  is  frequently  present. 

The  most  important  local  signs  are  : — 

(i)  Extensive  reflex  rigidity,  especially  in  the  upper  abdominal 
region,  but  generally  over  the  whole  abdomen,  both  sides  being 
equally  involved. 

The  degree  and  extent  of  the  reflex  rigidity  distinguish  acute 
perforation  of  the  stomach  from  all  other  conditions  which  enter  into 
the  differential  diagnosis.  Those  who  devote  their  attention  to  this 
sign  will  not  usually  find  any  difficulty  in  the  diagnosis. 

(2)  The  presence  of  gas  in  the  free  abdominal  cavity.  The  remarks 
already  made  in  connection  with  laceration  of  the  intestine  apply  here 
also  :  liver  dulness  is  usually  present,  and  there  is  no  escape  of  gas 
in  most  cases;  but  if  gas  is  present,  it  may  limit  itself  to  a  movable 
collection  at  the  uppermost  region  of  the  abdomen,  revealing  itself 
by  a  localized  metallic  note. 

(3)  Friction  murmur,  and  soft  friction  appreciable  by  the  hand 
over  the  gastric  area.  This  sign  is  rare,  but  if  present  is  of  great 
value. 

(4)  Rapidlv  increasing  dulness  in  the  flanks,  especially  on  the 
right. 

Important  as  it  is  to  diagnose  a  perforated  gastric  ulcer  early, 
nevertheless  we  must  not  make  this  diagnosis  just  because  the  patient 
happens  to  be  a  girl  at  an  age  when  gastric  ulcer  is  common.  We 
may  easily  be  misled  by  acute  intoxicatious,  especially  as  a  reliable 
history  is  not  often  obtainable  in  these  cases. 


SURGICAL    DISEASES    OF   THE    STOMACH  299 

Symptoms  of  a  perforated  gastric  ulcer  in  a  pregnant  girl  always 
suggest  poisoning — a  circumstance  not  exactly  creditable  to  the 
"stronger  sex." 

There  is  hardly  any  disease  of  the  abdomen  which  has  not  been 
confused  with  perforated  gastric  ulcer,  especially  cJiolecvsfifis,  pan- 
creatitis, rupture  of  a  pregnant  tube,  torsion  of  an  ovarian  tnnionr,  and 
acute  obstruction.  Even  acute  pneumothorax  has  been  taken  for  a 
gastric  perforation.     The  same  applies  to  the  crises  of  tabes. 

It  does  not  take  very  long  to  examine  the  reflexes,  and  the 
phvsician  has  a  just  cause  for  criticism  if  the  abdomen  of  a  tabetic  is 
opened  on  four  occasions  for  gastric  crises, -as  was  recently  reported. 

The  foregoing  remarks  on  rupture  of  a  gastric  ulcer  hold  good 
also  for  that  of  a  duodenal  ulcer.  In  both  cases  an  operation  is 
indicated.  The  diagnosis  of  duodenal  ulcer  can  be  made,  at  any  rate 
with  probability,  from  a  consideration  of  the  antecedent  symptoms 
(see  above). 

In  the  present  age  of  necessary  and  of  unnecessary  gastro-entero- 
stomies,  the  presence  of  an  operation  scar  in  the  epigastrium  indicates 
a  special  type  of  perforated  ulcer — perforation  of  a  peptic  nicer  in  the 
region  of  the  gastro-intestinal  anastomosis.  This  form  of  ulcer  is  one 
of  the  darkest  spots  in  the  whole  of  gastric  surgery. 


(4)  CICATRICIAL   STENOSES. 

We  get  much  more  time  for  observation  in  the  late  effects  of  ulcers, 
i.e.,  in  cicatricial  stenosis  of  the  pylorus,  than  we  do  in  a  perforated 
ulcer.  We  shall  begin  with  a  brief  review  of  the  clinical  symptoms 
of  the  various  degrees  of  stenosis. 

The  severe  cases  are  the  easiest  to  recognize.  Increasing  emacia- 
tion and  diminution  of  the  amount  of  urine  are  always  observed  in 
these.  Hysterical  or  neurasthenic  vomiting  may  reduce  the  body 
to  the  state  of  a  mere  skeleton,  and  greatly  diminish  the  urine,, 
but  this  form  of  vomiting  usually  comes  on  soon  after  food,  in 
contrast  to  the  vomiting  of  retention.  The  functional  examination  of 
the  stomach  in  these  hysterical  cases  will  show^  varying  abnormalities 
in  the  composition  of  the  gastric  juice,  and  indicate  that  there  is  no 
genuine  retention. 

Among  my  most  grateful  patients,  I  reckon  a  young  girl  who  had 
undergone  dietetic  treatment  for  many  years,  and  finally  had  to  be 
fed  per  rectum,  or  subcutaneously,  on  account  of  persistent  vomiting.. 
Both  the  patient  and  her  parents  would  gladly  have  consented  tO' 
some  curative  operation.  The  history  showed  that  the  vomiting 
followed  immediately  upon  a  meal,  and  examination  of  the  stomach 
showed  that  its  chemical  and  motor  functions  were  normal.  The 
removal  of  the  patient  from  her  surroundings  and  the  strict  injunction 
not  to  vomit,  worked  wonders.  The  vomiting  ceased  forthwith,  all 
20 


300      SURGICAL   DISEASES   OF   THE   ABDOMINAL   AND    PELVIC   VISCERA 

food  was  well  tolerated,  and  the  body  weight  increased  by  12  kilos 
within  a  few  weeks.     The  cure  persisted  for  years. 

Unfortunately  similar  cases  are  often  subjected  to  operation,  either 
because  the  surgeon  does  not  diagnose  them,  or  because  he  is  un- 
acquainted with  the  significance  of  psychical  therapeutics,  i.e.,  treat- 
ment by  suggestion.  If  these  measures  fail,  the  benefit  of  operation 
is  only  of  brief  duration.  The  neurologist  justifiably  upbraids  the 
surgeon  on  account  of  a  number  of  avoidable  gastro-enterostomies, 
and  for  displaying  too  much  operative  zeal.  We  may  hope  that  the 
neurologist  will  never  deserve  the  retort  of  treating  patients  by  sug- 
gestion, without  the  previous  indispensable  exhaustive  examination 
of  the  stomach,  until  it  was  too  late  for  the  necessary  operation.  No 
operation  witlioiit  previous  careful  investigation  of  the  functions  of  the 
stomach,  neither  any  psychotherapy  witlwut  the  same  precaution. 

The  cases  wherein  there  is  no  vomiting,  but  wherein  the  gastric 
contents  are  emptied  into  the  duodenum  with  painful  colic,  are  more 
difficult  to  diagnose.  If  the  abdomen  is  watched  for  some  time,  at 
any  rate  in  thin  subjects,  the  stomach  will  be  seen  to  rear  itself  up 
against  the  obstruction,  so  that  its  entire  shape  can  be  discerned 
through  the  skin.  Sometimes  this  occurs  in  a  regular  rhythm  of 
eighteen  seconds.  The  fear  of  the  pain  causes  these  patients  to  reduce 
their  food  to  a  minimum,  and  therefore  they  become  weaker  and 
weaker,  even  before  the  outset  of  the  vomiting. 

It  is  possible  to  estimate  precisely,  in  these  cases,  the  degree  of 
disturbance  in  the  motor  functions  and  the  amount  of  retention,  by 
means  of  repeated  examinations  with  a  test  breakfast. 

The  milder  cases  are  susceptible  of  improvement  under  appro- 
priate diet,  but  the  patients  are  often  glad  enough,  after  a  time,  to 
obtain  surgical  relief. 

An  individual  can  survive  a  great  deal  of  inconvenience  from  a 
narrowing  of  the  pylorus.  I  have  seen  a  case  of  constriction  of 
pylorus  by  a  cicatricial  band  on  its  exterior  surface,  which  reduced 
the  pylorus  to  an  external  diameter  of  7  to  8  mm.  When  the  patient 
■came  under  surgical  treatment,  he  was  in  extremis,  with  a  weight 
of  37  1^'g-  His  weight  had  doubled  a  few  months  after  gastro- 
enterostomy. 

The  main  symptom  of  stenosis,  as  is  evident  from  what  has  been 
said  already,  is  retention  of  the  gastric  contents.  This  retention 
varies  from  a  slight  interference  with  the  passage  of  the  food  to  a 
complete  obstruction.  The  well-known  methods  for  the  clinical 
examination  of  gastric  motility,  which  enable  us  to  detect  even 
slight  disturbances,  are  employed  to  demonstrate  this  stagnation  of 
food.  If  the  disturbance  is  only  slight,  the  question  as  to  its  functional 
or  organic  origin  arises — whether  it  is  due  to  muscular  weakness  or 
defective  innervation  of  the  stomach,  i.e.,  general  atony,  or  whether 
it  is  due  to  spasmodic  contraction  of  the  pylorus  consequent  on  an 
ulcer  at  that  situation,  or  elsewhere  in  the  body  of  the  stomach.     A 


SURGICAL   DISEASES   OF   THE   STOMACH  301 

comparison  of  the  physical  signs  with  the  skiagram  is  of  great  value 
in  arriving  at  a  decision. 

We  must  distinguish  between  the  retention  of  large  portions  of 
solid  food  and  that  of  liquid  contents.  The  former  condition  without 
the  latter  only  occurs  when  there  is  an  organic  change,  i.e.,  in  cases 
Avherein  large  fragments  of  food  are  detained  within  excavated  ulcers 
■or  ulcerated  tumours,  or  wherein  an  organic  stricture  permits  liquids 
to  pass,  but  not  solid  masses  of  any  large  size.  If,  on  washing  out 
the  stomach  in  the  morning,  we  find  whortleberries,  damson  skins  or 
pieces  of  orange,  which  were  eaten  the  previous  evening,  we  may 
conhdently  assume  that  some  organic  change  exists,  whatever  be  the 
result  of  other  tests. 

Skiagrams  furnish  the  clearest  evidence  of  the  retention  of  liquid 
or  mucilaginous  contents,  for  they  enable  us  to  watch  quietly  the 
whole  process  of  the  emptying  of  the  stomach,  without  disturbing  it, 
by  the  introduction  of  a  tube.  It  is,  however,  indispensable  that  the 
examinations  should  always  be  made  in  the  same  way,  with  an 
indifferent  contrast-forming  substance,  and  that  the  vehicle  should 
always  be  the  same. 

If  we  find  that  the  stomach  is  couipkidv  empty  within  six  hours, 
after  a  carbohydrate  contrast-forming  meal,  it  follows  that  there  is  no 
organic  obstruction,  or  if  there  be  one,  that  it  is  compensated  for,  by 
increased  muscular  power.  This  increased  peristalsis  can  be  seen 
very  well,  both  on  the  screen  and  on  the  plate.  But  we  must  be  on 
our  guard  against  error,  for  increased  peristalsis  occurs  in  tabes,  and 
in  a  slighter  degree  in  hysteria,  so  that  these  diseases  must  be  excluded 
before  deciding  that  an  early  stenosis  exists. 

The  delay  of  a  few  hours  iu  tJie  euiptying  of  the  stouiacli,  without 
any  subjective  symptoms,  indicates  simple  uiuscular  weakness,  and 
possesses  no  surgical  importance.  Delay,  accompanied  by  colicky 
pains,  strongly  suggests  pyloric  spasm  or  some  organic  change.  It  is 
not  always  easy  to  differentiate  between  these  two  conditions,  more 
especially  as  the  two  are  often  associated — for  instance,  when  a  local 
spasm  supervenes  upon  an  ulcer,  which  often  occurs  in  cases  of  hour- 
glass contraction.  The  more  persistent  these  derangements  are,  the 
more  likely  are  they  to  be  due  to  organic  narrowing,  and  the  less 
effect  will  atropine  have  on  the  physical  condition  revealed  by  the 
X-rays. 

If  the  bulk  of  the  meal  is  still  within  the  stomach  after  six  hours, 
and  if  the  viscus  is  not  completely  empty  after  twelve  hours,  organic 
stenosis  is,  at  any  rate,  very  probable. 

So  far,  the  symptoms  are  the  same,  wherever  the  situation  of  the 
stenosis. 

Whereas  it  was  hitherto  assumed  that  a  stenosis  must  be  at  the 
pylorus,  and  that  any  other  situation  was  quite  exceptional,  more 
extensive  surgical  experience  and  skiagraphy  have  shown  that  ulcer- 
ative constriction  occurs  much  more  frequently  in  the  body  of   the 


302       SURGICAL    DISEASES    OF   THE    ABDOMINAL   AND    PELVIC    VISCERA 


stomach  than  was  formerly  reahzed — hour-glass  stomach  due  to 
cicatrization  of  an  ulcer.  The  s\'mptoms  of  stenosis  are  common 
to  both  situations,  but  there  are  also  certain  clinical  differences. 

Let   us   begin    with    pyloric   stenosis,   which    is    the    much    more 
common  form.     This  is  recognized  in  the  skiagram  by  the  dilatation 


{a)  {5) 

Peristaltic  restlessness  of   the         Small  flat  ulcer  on  the  lesser 
stomach  in  tabes.  curvature  with  spastic  contrac- 

tion of  the  greater  curvature. 


Hour-glass  stomach,  partly 
organic  and  partly  spastic,  in 
a  case  of  ulcer  of  the  lesser 
curvature. 


Cicatricial  hour-glass  stomach 
with  deep  ulcer  on  lesser  curva- 
ture (Haudek's  diverticulum). 


Cicatricial  stenosis  of  pylorus,         Loss  of  shadow  due  to  cancer 


with     extreme     dilatation 
stomach,  in  its  breadth. 


of    at  the  lesser  curvature. 


Fig  147.— Semi-diagrammatic  illustrations  of  X-ray  examination  of  the  stomach. 

of  the  stomach  in  its  breadth,  in  contrast  to  the  condition  in  ptosis 
when  the  organ  hangs  down  like  a  loose  sack  in  the  left  half  of  the 
abdomen,  reaching  as  far  as  the  pelvis  or  even  to  the  symphysis,  the 
pylorus  appearing  usually  just  in  front  of  the  spinal  column,  if  not  to 
the  left  of  it.     (Compare  figs,  i-jo  and  147.) 


SURGICAL   DISEASES   OF   THE   STOMACH 


303 


It  may  exceptionally  happen  that  the  entire  distension  of  the 
stomach  is  towards  the  left,  even  in  the  case  of  pyloric  stenosis. 
This  will  occur  when  the  stomach  has  originally  been  "displaced,  and 
the  pylorus  has  been  fixed  in  the  middle  line,  or  to  the  left  of  it,  by 
perigastric  adhesions. 


Loss  of  shadow  due  to  cancer 
of  the  greater  curvature. 


W  (i 

Cancerous  degeneration    of  Cancer  of  pylorus.     Its  duo- 

antrum  pylori,  with  its  com-      denal  end    badly   defined,    in- 
plete  absence  from  the  shadow,     stead     of     the     normal     clear 

definition. 


Cancerous  hour-glass  stomach 

Fig.  147. — Semi-diagrammatic  illustrations  of  X-ray  examination  of  the  stomach 


Loss  of  shadow,  owing  to  a 
tumour  external  to  the  stomach. 


Cirrhosis  of  the  stomach, 
diffuse  scirrhus. 


In  this  connection  one  may  remark  that  the  term  dilataiion  of  the 
stomach  ought  to  be  discarded  from  the  nomenclature  of  gastric 
disease.  At  any  rate,  the  term  is  no  diagnosis,  although  it  is  still 
employed  in  this  sense  occasionally.  Dilatation  of  the  stomach  is  a 
result  of  various  diseases,  but  is  not  a  disease  of  itself.  If  gastric 
dilatation  is  discovered,  it  is  then  necessary  to  determine  its  cause. 


304      SURGICAL   DISEASES    OF   THE   ABDOMIXAL   AND   PELVIC   VISCERA 

In  davs  gone  bv,  the  stomach  tube  was  indiscriminately  prescribed 
for  ail  patients  with  dilated  stomach,  without  any  thought  being 
devoted  to  the  cause  of  the  trouble  :  but  we  may  hope  that  this  era 
has  finally  terminated. 

Having  established  the  diagnosis  of  pyloric  stenosis,  we  are  con- 
fronted by  the  question  as  to  its  innocence,  as  hitherto  assumed,  or 
its  possible  malignancy — a  matter  we  will  deal  with  in  discussing 
cancer  of  the  stomach. 

Extensive  adhesions  around  the  pylorus  occasionally  give  rise  ta 
symptoms  similar  to  those  of  stenosis,  although  the  calibre  of  the 
pylorus  may  be  quite  normal.  Many  surgeons  have  separated  these 
adhesions  with  permanently  successful  results,  but  it  is  hardly  possible 
to  make  an  accurate  diagnosis  before  the  abdomen  has  been  opened. 

Medio-gastric  stenosis  is  a  rare  variety  of  post-ulcerative  constric- 
tion, which  constitutes  hour-glass  contraction  of  the  stomach. 
The  diagnosis  mav  often  be  inferred  from  tlic  clinical  condition. 
The  case  will  apparently  be  one  of  pyloric  stenosis,  but  if  the 
epigastrium  and  left  hvpochondrium  are  percussed  on  several  occa- 
sions, varying  notes  will  be  elicited.  On  washing  out  the  stomach,, 
pure  water  runs  out  after  the  stomach  contents  are  emptied,  and  then 
suddenly  stomach  contents  will  again  run  out.  From  this  it  is- 
obvious  that  the  stomach  must  consist  of  two  cavities  connected  by 
a  narrow  channel.  This  can  be  proved  by  distending  the  stomach 
and  noting  the  hour-glass  form  through  the  abdominal  wall.  As  the 
inflated  air  passes  from  the  cardiac  to  the  pyloric  section  of  the 
stomach,  a  buzzing  sound  is  audible,  which  is  a  further  confirmator}^ 
point.  It  has  also  been  observed  that  liquids  introduced  sometimes- 
disappear  very  rapidly,  as  if  they  flowed  directly  into  the  pylorus- 
(Roux). 

Definite  evidence  is,  however,  only  furnished  by  a  properly  inter- 
preted skiagram.  Proper  interpretation  is  required  because  the  hour- 
glass stomach  appears  under  many  guises.  The  following  are  the 
possible  varieties,  with  their  characteristic  signs  : — 

(i)  ^Momentary  picture  of  a  peristaltic  wave,  with  an  evanescent 
contraction  of  the  larger  or  smaller  curvature,  circular  in  shape  and 
sharplv  defined;  variable  in  position. 

(2)  Persistent  spasm  in  the  vicinity  of  an  organic  lesion  (ulcer,. 
old  scar)  on  the  smaller  curvature.  Narrow,  deep,  sharply-defined 
contraction  on  the  larger  curvature  always  found  in  the  same  position 
(fig.  147,  h). 

(3)  Constriction  from  without  by  perigastric  bands.  The  con- 
striction is  also  narrow  and  sharply  defined,  the  stomach  sometimes 
appearing  to  be  divided  into  two.  Cannot  be  accurately  diagnosed 
before  operation. 

(4)  Constriction  by  a  round  band  from  the  liver,  embracing  the 
stomach.  The  constriction  is  sharply  defined,  but  not  of  a  very 
extreme  degree.     No  clinical  significance. 


SURGICAL   DISEASES   OF   THE   STOMACH  305 

(^)  Constriction  bv  cicatrized  ulcers — true  hour-glass  stomach. 
The  picture  often  resembles  the  condition  in  No.  2  ;  but  there  is  also 
an  incurving  of  the  lesser  curvature.  As  a  rule,  however,  the  stenosed 
portion  is  stretched  out  to  some  extent,  and  possesses  infundibuliform 
processes  on  both  sides,  forming  the  correct  shape  of  an  hour-glass. 
Haudek's  diverticulum  is  often  seen  on  the  lesser  curvature,  at  its 
narrowest  portion  or  near  it  (fig.  147,  d). 

(6)  Constriction  of  the  stomach  by  a  ring-shaped  carcinoma. 
The  constriction  is  not  well  defined,  or  may  be  irregularly  sinuous. 

Xos.  2  and  5  are  often  associated,  so  that  an   organic  narrowing^, 
which  in  itself  may  be  insignificant,  will  appear  on  the  skiagram  as  a 
complete  subdivision  of  the  stomach  shadow,  owing  to  a  simultaneous 
spastic  contraction. 

It  follows  from  the  foregoing  that  the  interpretation  of  a  skiagram 
of  the  stomach  is  no  easy  matter ;  at  any  rate,  it  is  no  easier  than  the 
clinical  methods  of  gastric  examination,  hitherto  in  vogue.  Neverthe- 
less skiagraphy  has  already  become  an  indispensable  adjunct  of  the 
examination,  in  most  cases. 

Pyloric  stenosis  of  infants  still  remains  an  unexplained  disease. 
Some  authorities  regard  it  simply  as  a  spasmodic  contraction,  others 
as  a  genuine  hypertrophy  of  the  pyloric  wall.  Probably  both  con- 
ditions occur.  It  is,  however,  established  that  operation  ought  to  be 
undertaken  if  the  infant  vomits  all  food,  without  bringing  up  any 
bile,  and  if  the  rigidity  of  the  stomach  can  be  appreciated.  The 
necessity  to  save  life  outweighs  all  theoretical  considerations. 

D.— CANCER  OF  THE  STOMACH. 

Gastric  patients  are  divisible  into  two  classes  :  (i)  Those  who  have 
suffered  with  their  stomachs  for  years,  some  patients  will  say  that 
they  have  always  suffered  ;  and  (2)  those  who  declare  that  they  have 
previously  enjoyed  the  digestive  powers  of  an  ostrich,  and  whose 
symptoms  are  of  ver}-  recent  date. 

We  will  first  consider  the  latter  class.  If  there  be  nothing  wrong 
with  the  other  viscera  and  indications  of  biliary  disease  are  absent,  if 
the  symptoms  cannot  be  explained  by  some  non-surgical  condition 
such  as  nephritis,  nor  by  recent  or  chronic  poisoning,  such  as  alcohol 
and  tobacco,  and  if  in  addition  the  patient  has  begun  to  lose  flesh, 
we  are  justified  in  thmking  of  cancer,  and  our  whole  examination 
must  be  directed  towards  settling  this  point.  The  gradual  and 
unexplained  onset  of  gastric  symptoms  in  a  patient,  hitherto  free 
from  indigestion,  is  a  most  significant  feature  of  this  disease. 

Chronic  dyspeptics  are  also  divisible  into  two  classes.  The  one 
class  always  adheres  to  a  "  diet,"  which  is  sometimes  prescribed  by 
an  authority  ;  at  other  times  is  merely  the  formula  of  some  nature- 
cure,  but  at  intervals  there  is  considerable  indulgence  in  the  pleasures 


306       SURGICAL   DISEASES   OF   THE   ABDOMINAL   AND   PELVIC   VISCERA 

of  the  table.  These  patients  often  get  alarmed  after  reading  some 
popular  article  on  medicine  and  consult  a  surgeon,  in  fear  of  cancer, 
although  they  are  not  really  any  worse  than  they  have  always  been. 
Even  these  patients  must  be  carefully  examined,  because  they  are 
just  as  susceptible  to  cancer  as  others.  As  a  rule,  nothing  will  be  found, 
and  unless  we  can  convince  them  that  they  ought  to  feed  like  other 
people,  we  shall  have  to  leave  them  to  resume  their  own  dietetic  ways. 
The  other  class  of  patients  consists  of  those  who  have  a  history 
pointing  to  ulcer  ;  they  may  be  suffering  from  severe  haemorrhages 
or  other  symptoms  previously  described,  which  indicate  that  they 
have  an  old  unhealed  ulcer,  or  that  they  may  be  subjects  of  a  recent 
ulcer.  But  we  must  not  lightly  dismiss  cancer  in  these  cases,  because 
this  disease  is  apt  to  develop  on  the  base  of  an  old  ulcer,  or  even  on 
its  scar.  Cancer  must  be  suspected  if  the  symptoms  have  lately 
assumed  a  new  aspect,  and  if  the  general  condition,  which  had  pre- 
viously been  unaltered  for  years,  has  become  worse  during  the  last 
few  weeks  or  months. 

We  have  no  accurate  information  as  to  the  frequency  of  the 
change  of  a  chronic  ulcer  or  its  scar  into  cancer.  Many  of  the  facts 
hitherto  advanced,  do  not  stand  criticism,  and  my  surgical  and 
pathological  experience  seems  to  indicate  that  the  frequency  of  this 
occurrence  has  been  exaggerated. 

Owing  to  the  diversity  of  the  symptoms  which  they  present,  it  is 
necessary  to  distinguish  between  growtJis  at  tJie  cardia,  groivths  at  the 
pylorus  and  cancer  of  the  hodv  of  the  stomach  itself,  the  last  usually 
originating  on  the  lesser  curvature.  As  the  symptoms  of  cancer  of  the 
cardia  resemble  those  of  oesophageal  cancer,  we  have  discussed  them 
in  connection  with  the  latter. 

Before  entering  into  details  of  the  various  forms,  we  shall  point 
out  some  general  diagnostic  signs  of  cancer  of  the  stomach. 

The  practitioner  usually  demands  three  signs  for  the  diagnosis  of 
cancer  of  the  stomach  :  viz.,  a  tumour,  haemorrhages,  and  chemical 
derangement,  sometimes  also  cancerous  cachexia.  This  kind  of 
diagnosis  is,  however,  a  relic  of  the  time  when  a  patient  with  cancer 
was  inevitably  doomed,  so  that  there  was  no  hurry  for  the  diagnosis. 
But  an  enormous  change  has  occurred  in  the  position  within  the  last 
twenty  years,  and  the  cure  of  the  patient  now  turns  upon  early 
diagnosis.  We  must,  therefore,  study  the  possibility  and  method  of 
attaining  an  early  diagnosis. 

We  must  first  discuss  the  signihcance  of  the  above-mentioned 
symptoms,  because  at  least  one  of  them  is  usually  present  when  the 
patient  consults  the  doctor. 

We  begin  with  the  question  of  tumour,  and  must  at  once  say 
that  if  one  is  found  it  is  not  an  unconditional  evidence  for  cancer, 
nor  is  the  absence  of  a  tumour  the  slightest  evidence  against  cancer. 


SURGICAL   DISEASES   OF  THE   STOMACH  307 

A  gastric  ulcer  may,  in  many  ways,  resemble  a  tumoui".  An  inflamed 
and  indurated  pylorus  may  feel  like  a  movable  tumour,  whose  size  is 
increased  by  the  functional  hypertrophy  of  the  adjoining  musculature. 
The  tumour  is  wider  towards  the  left  than  towards  the  right,  just  as 
in  an  early  pyloric  cancer.  In  other  cases  the  ulcerated  segment  of 
the  stomach  is  adherent  to  the  liver,  omentum  or  mtestine,  and  forms 
a  tumour  which  is  only  slightly  movable,  but  which  is  free  from 
the  abdominal  wall.  On  rare  occasions,  it  happens  that  an  ulcer  on 
the  anterior  surface  of  the  stomach,  which  is  on  the  point  of  perfora- 
tion, contracts  adhesions  to  the  abdominal  wall  and  leads  to  inflam- 
matory infiltration  thereof.  The  superficial  situation  of  this  swelling 
is  easily  recognized,  because  it  cannot  be  moved  independently  of 
the  abdominal  wall,  nor  does  it  move  independently  of  it  during 
respiration.  If  the  swelling  persists  for  any  length  of  time  it  may 
cause  phlegmonous  inflammation  of  the  abdominal  wall,  spontaneous 
perforation  and  the  development  of  a  gastric  fistula.  On  the  other 
hand,  a  tumour  may  be  absent  in  cases  which  are  otherwise  obviously 
cancer,  from  the  clinical  standpoint.     This  occurs  in  : — 

(i)  Flat  cancers,  chiefly  situated  on  the  posterior  wall  of  the 
stomach. 

(2)  Cancers  which  are  covered  over  by  the  liver,  especially 
frequent  at  the  lesser  curvature. 

(3)  Small  contracting  pyloric  cancers,  even  when  the  pylorus  is 
accessible  to  palpation. 

(4)  Soft  polypoid  cancers,  which  do  not  infiltrate  the  abdominal 
wall. 

It  follows,  therefore,  that  we  must  not  delay  our  diagnosis  of 
cancer  until  the  appearance  of  a  tumour.  But  there  is  no  justification 
for  the  apparent  paradox,  that  all  palpable  cancers  of  the  stomach  are 
too  late  for  radical  operation.  As  a  matter  of  fact,  some  of  the 
largest  growths,  i.e.,  those  of  the  cauliflower  variety,  have  the  best 
prognosis. 

Before  concluding  that  a  tumour  is  absent,  it  is  essential  that  we 
should  have  searched  for  it  properly.  If  the  patient  is  very  fat,  or  if 
the  reflex  rigidity  of  the  recti  is  very  great,  an  anaesthetic  is  required. 
In  other  cases,  repeated  examinations  without  anaesthesia  after  empty- 
ing the  stomach  and  bowels,  must  be  undertaken,  before  arriving 
at  a  positive  conclusion. 

The  patient  should  lie  fully  relaxed  in  a  horizontal  position.  The 
examiner  sits  at  his  side  and  feels  with  gentle  pressui'e  along  both 
sides  of  the  spinal  column,  from  above  downwards.  If  the  abdominal 
integuments  are  soft  and  not  too  firm  we  should  ordinarily  be  able 
to  feel  the  larger  curvature,  sometimes  also  the  pylorus,  and  even  the 
lesser  curvature,  but  this  depends  upon  the  degree  of  ptosis  of  the 
stomach.  An  indurated  pylorus  will  usually  appear  as  a  transverse 
movable    hard  pad,  which  recedes  from  the  palpating  finger  with  a 


308       SURGICAL   DISEASES   OF   THE   ABDOMINAL   AND   PELVIC   VISCERA 

sudden  jerk,  just  as  the  normal  structure.  In  the  case  of  thin  patients 
with  ptosis  one  must  avoid  being  confused  by  the  pancreas,  which 
can  sometimes  be  palpated  throughout  its  whole  length.  Confusion 
is  more  likely  to  occur  when  there  is  chronic  pancreatitis  or  cancer 
of  the  head  of  the  pancreas. 

We  do  not  always  find  the  growth  situated  where  we  usually 
suppose  the  stomach  to  be.  In  cases  of  ptosis,  the  whole  stomach, 
including  the  pylorus,  may  be  in  the  left  half  of  the  abdomen,  so- 
that  cancer  in  a  stomach  thus  displaced  will  be  encountered  on  the 
left  side,  occasionally  even  as  low  down  as  the  pelvis.  On  palpating 
such  a  tumour,  its  connection  with  the  stomach  will  be  suggested  by 
the  ease  with  which  it  can  be  pushed  over  to  the  right,  and  by  the 
fact  that  it  can  be  displaced  over  an  extent  which  corresponds  to 
the  segment  of  a  circle  around  the  normal  position  of  the  pylorus, 
A  more  striking  evidence  of  its  connection  with  the  stomach  is 
afforded  by  its  displacement  towards  the  right,  when  that  viscus  is- 
distended  with  gas. 

If  we  are  in  doubt  whether  the  tumour  is  connected  with  the 
stomach  or  with  the  transverse  colon,  we  must  endeavour  to  trace 
the  latter  from  the  hepatic  flexure,  by  palpation.  If  we  are  able  to- 
feel  the  transverse  colon,  in  its  entire  extent,  as  separate  from  the 
tumour,  obviously  it  cannot  be  connected  with  the  bowel,  and  there- 
fore probably  arises  from  the  stomach.  If  the  tumour  is  on  the  left 
side,  we  must  palpate  both  the  ascending  and  descending  limb  of  the 
splenic  flexure,  in  order  to  be  sure  that  it  is  not  connected  with  the 
bowel. 

For  the  sake  of  completeness,  it  should  be  mentioned  that  a 
tumour  originating  in  the  kidney  or  its  fatty  capsule  may  simulate 
a  tumour  of  the  stomach.  In  such  a  case,  the  skiagram  would  show 
the  stomach  displaced  and  compressed. 

There  is  not  much  to  say  about  haimorrhage.  It  merely  indicates 
the  existence  of  some  ulceration.  Every  tyro  knows  that  acute- 
arterial  haemorrhage  points  to  a  simple  ulcer,  and  that  coffee-grounds 
vomit  points  to  cancer.  But  exceptions  occur  in  both  directions. 
Sometimes  there  is  no  haemorrhage  visible  to  the  naked  eye  ;  and  to- 
wait  for  coffee-grounds  vomit  would  mean  to  miss  more  than  half 
the  cases  of  gastric  cancer.  Early  diagnosis  depends  in  great  measure 
on  the  repeated  microscopical  and  micro-chemical  examination  of 
the  syphoned-ofT  stomach  contents,  for  traces  of  blood  which  are 
otherwise  invisible.  If  such  traces  are  regularly  present,  we  may 
be  confident  that  there  is  at  any  rate  some  ulceration  within  the 
stomach.  Traces  of  blood  in  the  stools  would  lead  to  the  same 
conclusion,  with  the  reservation  that  the  blood  may  be  coming 
from  some  lower  site  in  the  digestive  canal,  especially  the  duodenum^ 

The  examination  of  the  cheiiiical  conditions  of  the  stomach  often 


SURGICAL    DISEASES   OF   THE   STOMACH  309 

furnishts  further  evidence,  and  the  following  four  statements  summarize 
the  information  hitherto  established  on  the  subject  : — 

(i)  Free  hydrochloric  acid  very  soon  disappears  in  most  cases  of 
cancer,  but  on  the  other  hand  the  absence  of  the  free  acid  or  even 
a  deficiency  of  the  combined  acid  is  in  no  sense  an  evidence  of 
cancer.  (In  those  cases  wherein  it  is  assumed  that  cancer  has  become 
engrafted  upon  an  ulcer,  the  free  hydrochloric  acid  may  persist  for  a 
considerable  time). 

(2)  The  presence  of  a  definite  and  intense  lactic  acid  reaction 
indicates  a  stenosis  caused  by  cancer  ;  but  on  the  other  hand  the 
absence  of  lactic  acid  is  not  an  argument  against  cancer. 

(3)  Even  if  there  be  no  definite  lactic  acid  reaction,  the  presence 
of  numerous  long  bacilli  (lactic  acid  bacilli)  strongly  suggests  cancer. 

(4)  The  increase  of  hydrochloric  acid,  or  decrease  of  the  hydro- 
chloric acid  deficiency  when  the  quantity  of  the  test  meal  for  ulcer 
is  raised,  contra-indicates  cancer.     (Gluzinski  and  Kocher.) 

We  now  come  to  the  fourth  of  the  above-mentioned  signs — the 
cancerous  cachexia.  Controversy  has  been  raging  around  this  subject 
for  some  decades,  but  it  is  quite  clear  now  that  much  of  what  was 
attributed  to  cachexia  is  really  due  to  the  functional  disturbance  of 
vital  organs,  to  repeated  haemorrhages,  to  ulceration  of  the  cancer 
and  septic  absorption.  All  these  factors  are  especially  active  in  cancer 
of  the  stomach.  Nevertheless,  recent  haematological  research  has 
shown  that  thei'e  is  something  real  in  the  old  conception  of  cancerous 
cachexia.  The  peculiar  sallow,  waxy  appearance  of  many  cancerous- 
patients,  which  strikes  the  experienced  observer  forthwith,  the  early 
depression  of  cardiac  force,  indicated  by  the  rapid  soft  pulse,  corres- 
pond to  blood  changes  which  are  imperfectly  understood,  but  which 
can  be  estimated  by  certain  qualities  of  the  serum,  such  as  the  increase 
of  its  antitryptic  index.  A  definite  increase  of  this  index,  to  about 
double  the  normal,  is  a  strong  evidence  of  cancer,  in  the  absence  of 
any  other  cause  (advanced  tubercle,  parenchymatous  goitre,  Graves's 
disease).  Unfortunately  the  determination  of  this  index  is  much  toO' 
complicated  a  process  for  the  use  of  the  general  practitioner,  and 
the  same  applies  to  all  the  other  serological  tests  for  cancer  which 
have  been  investigated  within  the  last  few  years. 

There  is  no  one  single  reliable  sign  of  cancer.  The  diagnosis 
must  be  based  on  the  combination  of  the  various  signs.  The  assist- 
ance which  may  be  derived  from  skiagraphy  will  be  referred  to  when 
discussing  the  special  forms  of  cancer. 

There  can  be  no  doubt  about  the  nature  of  the  disease,  if  circum- 
scribed nodules  can  be  felt  in  the  liver,  if  free  fluid  is  detected  within 
the  abdomen,  or  if  hard  glands  are  found  in  the  supra-clavicular 
fossce — as  first  described  by  Troisier  and  Virchow. 


3IO      SURGICAL   DISEASES   OF   THE   ABDOMINAL   AND   PELVIC   VISCERA 

(1)  CANCER  OF  THE  BODY  OF  THE  STOMACH. 

The  favourite  position  is  at  the  lesser  curvature.  Cancer  does 
occur  on  the  anterior  and  posterior  surface,  as  also  on  the  greater 
■curvature,  but  very  much  more  rarely.  All  cancers  of  the  body  of 
"the  stomach  characteristically  manifest  themselves  by  a  prolonged 
period  of  indefinite  indigestion,  until  the  increasing  anaemia,  the  size 
of  the  tumour,  and  secondary  malignant  peritonitis  indicate  the 
nature  and  situation  of  the  disease.  Occasionally,  the  growth  per- 
forates into  the  colon,  with  the  appearance  of  symptoms,  which  are 
obviously  due  to  a  fistula  between  the  stomach  and  large  intestine. 

These  cancers  are  concealed  beneath  the  liver  and  they  often 
cannot  be  felt,  but  the  persistent  tension  of  the  abdominal  integu- 
ments in  the  epigastrium  and  its  indefinite  resistance  eventually 
suggest  organic  disease  and  then  it  is  usually  too  late  for  operation. 
They  do  not,  as  a  rule,  give  rise  to  distinct  symptoms  until  they 
invade  the  pylorus.  Most  of  the  too-late  diagnoses — whether  due 
to  the  neglect  of  the  patient  or  of  the  practitioner — fall  within  this 
group,  and  tragically  enough  this  fate  fell,  a  few  years  ago,  to  the  lot 
■of  a  surgeon  who  had  distinguished  himself  by  his  work  on  the  early 
operation  for  gastric  cancer. 

As  we  shall  soon  see,  these  cancers  could  be  demonstrated  by 
skiagrams  before  they  give  rise  to  clinical  symptoms ;  but  in  the 
absence  of  symptoms  there  are  no  indications  of  illness,  and  therefore 
advice  is  not  sought. 

The  anatomical  peculiarities  and  the  clinical  details  of  these 
cancers  permit  of  their  division  into  the  following  four  varieties  : — ■ 

(i)  Superficial  cancer,  "rodent  ulcer  of  the  stomach,"  can  only  be 
felt  in  the  late  stages.  The  skiagrams  are  characterized  by  a  mere 
faintness  of  the  shadow  in  the  region  of  the  cancerous  infiltration, 
rather  than  by  circular  areas  where  there  is  real  loss  of  shadow. 

(2)  Protuberant  Broken-doivn  Cancer  witli  Deep  Ulceration  in  the 
Centre. — This  is  the  most  frequent  variety  of  cancer  of  the  body  of 
the  stomach,  and  is  situated  astride  of  the  lesser  curvature,  like 
a  saddle.  Unless  concealed  by  the  liver,  it  can  be  felt  earlier  than 
the  flat  cancer.  It  appears  in  the  skiagram  as  a  well-defined,  roundish 
area,  from  which  the  shadow  is  absent.  As  such  light  areas  may  also 
be  due  to  remains  of  food  not  derived  from  the  bismuth  meal,  it  is 
necessary  to  confirm  the  result  by  repeated  examination.  Mistakes 
may  also  arise,  from  tumours  outside  the  stomach  pressing  thereon 
(fig.  147,  /).  This  shows  how  important  it  is  to  interpret  the  skiagram, 
in  relation  to  the  existing  clinical  signs,  for  the  diagnosis  of  gastric 
■disease  based  upon  X-rays  alone  is  not  of  great  value. 

(3)  The  polypoid  form  of  gastric  cancer  is  also  recognized  by  areas 
of  loss  of  shadow.  Its  consistence  may  allow  of  its  easy  palpation,  or 
it  may  be  so  soft  that  it  cannot  be  felt  through  the  stomach  wall,  even 
when    the   abdomen    is    opened.     These    forms   are    liable   to    bleed 


SURGICAL   DISEASES   OF   THE    STOMACH  311 

freely,  and  they  are  clinically  characterized  by  anaemia.  These  are  the 
cases  which  are  often  regarded  for  months  as  pernicious  anaemia, 
until  a  careful  examination  reveals  the  diagnosis.  Every  case  of 
pernicious  anaemia  ought  to  be  subjected  to  an  exhaustive  examina- 
tion of  the  stomach,  and  a  skiagram  should  be  taken.  In  one  of  our 
cases,  the  diagnosis  was  established  by  a  piece  of  tissue  obtained  by 
washing  out  the  stomach  ;  in  another  case,  a  girl,  aged  24,  a  tumour 
could  actually  be  felt. 

(4)  The  clinical  signs  of  diffuse  cancerous  cirrJiosis  of  the  stomach 
(Brinton's  cirrhosis,  linite  plastique  of  French  authors)  depend  upon 
the  fact  that  the  organ  has  become  converted  into  a  rigid  tube  of 
small  capacity  (pocket-flask  stomach).  Vomiting  immediately  after 
a  meal  is,  therefore,  the  chief  symptom,  which  is  liable  to  suggest  the 
regurgitation  due  to  a  low  oesophageal  cancer,  or  to  a  carcinoma  of 
the  cardia.  A  tube  can  be  introduced  into  the  stomach  quite  easily,, 
but  the  viscus  cannot  be  distended  nor  can  any  large  amount  of  fluid 
be  retained.  If  the  growth  can  be  felt  distinctly,  it  appears  as  a 
difluse  or  cylindrical  resistance  in  the  upper  part  of  the  epigastrium. 

This  diffuse  contraction  of  the  stomach  is  recognized  on  the 
skiagram  as  a  narrowing  of  the  shadow.  As  a  rule,  the  change  affects 
the  uppermost  portion  of  the  stomach  last,  and  then  the  shadow  of 
the  stomach  has  a  funnel-shaped  appearance. 

(2)  CANCER  OF  THE  PYLORUS. 

The  symptoms  of  pyloric  cancer  are  much  more  definite,  and  it 
is  therefore  easier  to  establish  an  early  diagnosis.  The  principal 
symptoms  are  due  to  mechanical  obstruction,  just  as  in  cicatricial 
stenosis  at  the  pylorus.  The  same  trend  of  manifestations  occurs  in 
both  conditions  :  (i)  Pciinful  gastric  peristalsis,  often  visible  tJi rough  the 
ahdouiinal  ivall  (fig.  148)  ;  (2)  retention  wliicli  can  he  deuioustrated  by 
the  stomach  tube,  and  (3)   retention  vomiting. 

We  must  not  delay  our  diagnosis  until  these  signs  are  fully 
developed.  Epigastric  pressure,  from  which  a  patient  has  hitherto 
been  free,  coming  on  after  meals,  or  colicky  pains — even  if  only 
slight — in  the  gastric  region,  occurring  periodically  during  digestion,, 
are  symptoms  demanding  careful  examination,  which  will  usually 
show,  after  the  use  of  the  stomach  tube,  that  the  food  remains  in  th& 
stomach  too  long.  As  a  rule,  there  is  no  vomiting  at  all,  in  this  stage. 
A  skiagram,  which  is  indispensable  when  these  clinical  symptoms  are 
present,  usually  shows  the  following  points  : — 

The  impression  taken  immediately  after  the  bismuth  meal  shows 
a  normal  outline  ;  at  any  rate,  the  dilatation  in  the  transverse  diameter,, 
which  is  so  significant  of  post-ulcerative  stenosis,  is  absent.  At  most,, 
the  region  of  the  antrum  pylori  may  appear  somewhat  distant.  On 
the  other  hand,  we  may  be  struck  by  the  presence  of  deep  peristaltic 
waves,  in  one  impression  or  the  other.  It  is  especially  noticeable 
that  the  stomach  shadow  is  not  well  marked  in  the  pyloric  region.. 


312      SURGICAL   DISEASES   OF   THE   ABDOMINAL   AND    PELVIC   VISCERA 

The  stomach  looks  as  if  it  had  been  cut  off  transversel}^  and  its 
boundary  hne  presents  irregularities  which  remind  one  of  the  areas 
of  missing  shadow  which  occur  in  cancer  of  the  body  of  the  stomach. 
We  must  be  on  our  guard  against  deception  also  here.  A  dis- 
tended gall-bladder,  probably  with  inflammatory  adhesions  to  the 
pylorus,  may  extinguish  the  shadow  in  the  pyloric  region.  This  is 
especially  likely  to  happen  through  remains  of  food  not  derived 
from  the  bismuth  meal.  It  is,  therefore,  imperative  to  confirm  any 
apparently  pathological  condition  by  a  second  examination,  in  the 
right  lateral  posture,  if  necessary. 


Fig.  148. — Pyloric  stenosis  due  to  cancer.     Attack  of  gastric  rigidity.     (Stomach  not 

artificially  distended.) 


Sometimes,  a  tapering  or  conical  process  of  the  stomach  shadow 
indicates  the  path  by  which  the  food  makes  its  way  through  the 
cancerous  masses. 

If  examinations  are  made  after  six,  twelve,  or  twenty-four  hours, 
the  stomach  is  generally  found  partially  full,  thus  confirming  the 
clinical  evidence  of  retention.  The  longer  the  disease  has  lasted  the 
greater  is  the  food  residue,  the  wider  is  the  stomach  shadow  and  the 
nearer  does  the  picture  approximate  that  of  post-ulcerative  stenosis 
of  the  pylorus.     But  whereas  in  the  latter  the  boundary  line  of  the 


SURGICAL   DISEASES   OF   THE    BILIARY    PASSAGES 


313 


stomach  shadow  is  sharply  defined,  in  cancer  we  ahiiost  always  find, 
in  all  its  stages,  that  the  shadow  is  cut  across  towards  the  pylorus,  or 
at  any  rate  that  its  border  is  mdefinite  and  irregularly  wavy.  ^ 

Cancer  of  the  stomach  often  begins  on  the  lesser  curvature,  but 
is  not  recognizable  until  it  invades  the  pylorus  and  constricts  it. 
If  we  cannot  diagnose  it  from  the  history  and  the  results  of  palpation, 
it  can  often  be  detected  on  the  skiagram  by  the  loss  of  shadow 
extending  considerably  towards  the  left. 


CHAPTER  XLI. 
SURGICAL  DISEASES  OF  THE  BILIARY  PASSAGES. 

Notwithstanding  the  better  appreciation  of  the  nature  of  gall-stone 
disease,  which  we  have  gained  during  the  last  twenty  years,  there  still 
remain  some  practitioners  in  whose  minds  the  ideas  of  "jaundice" 
and  "gall-stones"  are  indissolubly  connected.  We  still  hear  the 
assertion  "  there  are  no  gall-stones  because  the  patient  has  no  jaundice." 
Jaundice  is  a  symptom  which  may  occur  in  gall-stone  disease,  but  is 
not  essential  thereto,  and  is  moreover  present  in  many  other  diseases. 

If  a  patient  informs  us  that  his  liver  is  affected,  or  if  we  have  the 
impression  that  he  is  so  suffering,  our  first  thoughts  should  be  of  the 
*'  medical "  diseases— simple  biliary  catarrh,  the  various  forms  of 
hepatic  cirrhosis,  and  acnte  yelloiv  atrophv  of  the  liver. 

If  a  patient  with  indigestion  but  without  pain,  becomes  yellow  but 
otherwise  remains  well,  we  must  diagnose  catarrlial  jaundice.  But  if 
the  general  condition  is  profoundly  affected,  and  the  temperature  is 
high,  the  disease  is  infective  jaundice,  which  may  also  occur  in  the 
epidemic  form.  This  also  constitutes  the  rare  malady  known  as 
Weil's  disease.  If  a  high  degree  of  jaundice  is  associated  with  sym- 
ptoms of  severe  general  illness  and  rapid  loss  of  strength,  we  should 
assume  either  acute  yelloiv  atropliy  of  the  liver,  as  a  result  of  poisoning 
(phosphorus,  arseniuretted  hydrogen)  or  some  form  of  septic  infection. 
A  certain  amount  of  jaundice,  without  any  profound  anatomical 
changes  in  the  liver,  often  exists  in  acute  septic  conditions,  especially 
in  septic  peritonitis,  and  all  experienced  observers  are  acquainted  with 
the  terrible  dirty  greenish  look — due  to  the  yellow  of  the  jaundice 
combined  with  the  blue  of  the  cyanosis — of  patients  who  have  suc- 
cumbed   to  this  disease.     A  patient  who  gets  about  for  years,  with 


314      SURGICAL   DISEASES   OF   THE   ABDOMINAL   AXD    PELVIC    VISCERA 

more  or  less  jaundice,  but  without  any  particular  pain,  but  who  com- 
plains occasionally  of  slight  feverish  symptoms  and  a  general  deterior- 
ation of  his  health,  must  be  suspected  of  suffering  from  Jivpciirophic 
cirrliosis  of  the  liver — which  is  mereh^  a  chronic  infection  of  the  organ 
with  acute  exacerbations. 

The  jaundice  of  Banti's  disease  should  be  mentioned  here,  in. 
which  condition  the  enlargement  of  the  liver  is  associated  with  great 
splenic  hypertrophy.  Secondary  and  tertiary  syphilis  may  also  pro- 
duce jaundice. 

The  above  comprise  all  the  usual  conditions  which  may  suggest 
forms  of  gall-stone  disease.  But  if  the  patient's  "  liver  trouble  "  does- 
not  appear  to  fit  in  an}'  of  these  categories,  we  are  justified  in  conclud- 
ing, by  exclusion,  that  the  case  is  probably  one  for  surgical  treatment. 
We  should  accordingly  think  of  gall-stones,  malignant  growth,  abscess 
of  the  liver  and  hydatid  cyst. 

We  have  just  included  Banti's  disease  among  purely  medical 
diseases,  but  this  is  not  quite  accurate,  for  good  results  have  followed 
extirpation  of  the  spleen  in  this  condition.  The  difficulty  consists 
in  the  fact  that  our  conception  of  the  disease  is  not  definite,  either 
from  the  clinical  or  etiological  standpoint.  The  condition  is  pro- 
bably a  composite  one.  Furthur  experience  is  necessary  to  clear  up 
the  matter. 

We  may  now  apph^  our  diagnostic  reflections  to  a  few  concrete 
cases. 

(1)   GALL-STONE  COLIC. 

In  one  group  of  cases,  pain  is  the  predominant  feature.  The 
patient  is  seized,  at  rare  or  frequent  intervals,  with  severe  pain 
in  the  upper  part  of  the  abdomen  or  more  definitely  in  the  gall- 
bladder region.  Nothing  but  morphia  suffices  to  relieve  the  pain 
which,  however,  does  not  last  more  than  a  few  hours,  or  at  most, 
a  day.  There  is  usually  no  rise  in  temperature,  nor  is  there,  as  a 
rule,  any  jaundice,  so  that  the  patient,  and  often  the  doctor,, 
diagnoses  "  colic."  But  gastric  colic  is  really  yerv  different  to  gall- 
stone colic,  both  in  its  onset  and  in  its  nature.  Pains  arising  in 
the  stomach  generall}'  radiate  to  the  left  and  towards  the  back  ;  biliaiy 
colic  radiates  towards  the  right,  even  as  far  as  the  right  shoulder. 
If  gastric  pain  is  caused  by  an  ulcer,  it  is  increased  on  taking  solid 
food.  If  caused  by  hyperacidity,  food  relieves  the  pain.  In  both 
cases  the  pain  comes  on  almost  regularly  at  definite  hours  of  the- 
day  or  night.  The  pain  in  an  acute  attack  of  gall-stones,  so-called 
biliary  colic,  is  quite  independent  of  food  and  it  occurs  at  irregular 
interyals  of  months  or  years.  This  also  differentiates  it  from  the 
pain  of  duodenal  ulcer,  which  is  situated  on  the  right  side  and 
comes  on  at  the  completion  of  gastric  digestion.  This  is  termed 
*'  hunger  pain." 


SURGICAL    DISEASES    OF   THE    BILIARY    PASSAGES  315 

After  an  attack  of  gall-stones  it  sometimes  happens  that  somewhat 
less  severe  but  more  persistent  or  periodical  pains  remain.  These  are 
apt  to  cause  confusion.  They  indicate  that  stones  are  still  present, 
or  that  the  attacks  have  led  to  advanced  anatomical  changes. 

In  other  cases  there  are  no  attacks  at  all  ;  the  disease  is  only 
betrayed  by  certain  indefinite  digestive  troubles,  the  origin  of  which 
may,  however,  be  suspected  from  the  pain  fulness  on  deep  pressure  over 
the  region  of  the  gall-bladder.  From  this  condition,  it  is  only  one 
step  to  the  cases  of  gall-stones  wherein  the  symptoms  are  quite 
latent — constituting  95  per  cent,  of  the  whole.  This  explains  the 
impossibility  of  making  a  diagnosis  in  so  many  of  the  cases. 

We  may  now  return  to  the  attack  of  colic  itself.  This  may  be 
mistaken  for  any  acute  painful  seizure  in  the  upper  abdomen,  viz., 
for  pain  caused  by  hernia  of  the  epigasiriiiiu  or  innbilicus,  renal 
colic,  and  the  severe  conditions  to  be  described  in  the  following 
section. 

Biliary  colic  may  be  distinguished  from  renal  colic,  even  in  the 
cases  where  there  is  no  palpable  swelling  to  assist  in  localization, 
by  the  position  of  the  reflex  muscular  rigidity.  If  we  press 
simultaneously  in  front  of  and  behind  the  painful  region,  in  a 
case  of  renal  colic,  the  lumbar  muscles  will  become  rigid,  whereas 
in  a  case  of  biliary  colic,  it  is  the  right  rectus  which  becomes 
rigid.  It  has  been  stated  that  in  gall-stone  disease  there  is  a  particu- 
larly characteristic  painful  spot  close  to  the  right  side  of  the  spine 
below  the  twelfth  rib ;  but  one  must  use  this  diagnostic  point  with 
discrimination. 

In  order  to  explain  the  mild  attacks  of  gall-stone  disease,  on 
an  anatoinical  basis,  we  must  assume  that  the  stones  are  incar- 
cerated in  the  gall-bladder,  cystic  duct  or  common  bile  duct,  and 
that  the  degree  of  surrounding  inflammation  is  very  slight  indeed, 
passing  off  very  i-apidly  after  having  attained  its  height  within  a 
few  hours  of  onset.  Unless  recuri-ences  are  very  frequent,  surgical 
aid  is  unnecessary.  We  will  discuss  the  position,  of  the  stone  in 
connection  with  other  forms  of  cholelithiasis  ;  but  it  is  usually  very 
difficult  to  localize  it  in  mild  attacks.  The  discovery  of  the  stone 
in  the  stools  after  the  attack  often  shows  that  the  pains  are  due 
to  the  extrusion  of  the  calculus.  Some  patients  are  able  to  exhibit 
a  stone  for  each  attack.  There  is  no  jaundice  in  these  slight  attacks 
because  the  obstruction  of  the  common  duct  is  too  brief. 

The  attacks  of  pain  caused  by  adjacent  adhesions  are  sometimes 
indistinguishable  from  mild  biliary  colic.  These  attacks  may  occur 
whether  the  stone  has  passed  naturally  or  has  been  removed  by  the 
surgeon. 

It  is  often  important  to  be  able  to  decide  whether  attacks  of 
pain  of  which  a  patient  has  complained  were  really  due  to  gall- 
stones. Two  practical  rules  are  applicable  in  this  connection.  The 
patient  is  able  to  go  to  his  doctor  for  very  many  attacks  of  pain, 
but  the  doctor  is  obliged  to  come  to  the  patient  for  biliary  colic. 
21 


3l6       SURGICAL   DISEASES   OF   THE   ABDOMINAL   AND    PELVIC   VISCERA 

An  anodyne  prescription  suffices  for  ordinary  pain,  but  a  hypodermic 
injection  of  morphia  is  indispensable  in  the  pain  of  gall-stones. 
Exceptions  are  rare. 

(2)  ACUTE  CHOLECYSTITIS. 

The  following  case  raises  somewhat  different  problems  of 
differential    diagnosis,    in    regard    to    acute    biliary    colic. 

A  patient  is  suddenly  seized  with  symptoms  of  pyrexia  and  severe 
pain  in  the  right  side  of  the  abdomen.  He  vomits  on  one  or  more 
occasions,  indicating  peritoneal  irritation.  The  colour  of  the  skin 
is  normal,  the  pulse  is  good,  the  abdominal  muscles,  especially  on 
the  right  side,  are  tense  or  become  so,  as  soon  as  they  are  touched,  and 
we  think  of  appendicitis,  because  of  its  frequency  or  perhaps  because 
it  is  in  fashion.  On  careful  examination,  it  will,  however,  be  found 
that  the  centre  of  the  painful  area  and  the  rigid  musculature  is  not 
situated  in  the  line  joining  the  anterior  superior  spine  and  the 
umbilicus,  or  below  it,  as  is  the  rule  in  appendicitis,  but  higher  up 
in  the  region  of  the  gall-bladder.  Percussion  probably  shows  that 
the  liver  dulness  projects  below  its  normal  limits,  even  extending  as 
far  as  the  level  of  the  umbilicus.  If  palpation  is  possible,  despite 
the  muscular  rigidity,  an  area  of  resistance,  with  its  lower  border 
circular  in  shape,  will  be  felt,  connected  with  the  liver.  If  this  be 
the  physical  condition  found,  there  can  be  no  doubt  that  the  case  is 
one  of  acute  cholecystitis,  and  if  the  pyrexia  persists  for  many  days 
it  is  certainly  of  a  suppurative  character.  The  position  of  the  pain 
and  the  pyrexia  often  suffice  for  the  diagnosis,  without  it  being 
possible  to  demonstrate  the  typical  lobular  or  tongue-shaped  area 
of  resistance.  In  such  case  we  may  assume  that  a  contracted  gall- 
bladder, concealed  under  the  liver,  has  become  inflamed,  and  we  will 
generally  obtain  an  old  history  of  gall-stones,  in  confirmation  of  this 
assumption. 

A  recent  perforation  of  a  gastric  or  duodenal  ulcer  might  suggest 
acute  cholecystitis.  But  in  perforation,  the  reflex  muscular  rigidity 
very  quickly  affects  the  whole  abdomen,  and  generalized  peritonitis 
soon  sets  in  if  the  case  is  neglected,  symptoms  which  only  occur 
in  cholecystitis  if  an  infected  gall-bladder  perforates  into  the  free 
abdominal  cavity. 

Pancreatitis  and  pancreatic  hcBuwrrhage  should  also  be  mentioned 
in  this  connection. 

If  the  gall-bladder  and  appendix  were  invariably  in  their  normal 
positions,  differential  diagnosis  would  be  very  easy.  This  is,  how- 
ever, not  the  case.  Sometimes  the  gall-bladder  reaches  as  far  as 
the  ileo-cjecal  region,  whether  the  liver  be  movable  or  not.  But 
much  more  frequently,  the  appendix  is  high  and  directed  outwards. 


SURGICAL   DISEASES   OF   THE   BILIARY   PASSAGES  317 

At  other  times  its  position  is  in  close  proximity  to  the  gall-bladder 
(fig.  143,  //)  especially  when  there  is  a  "  mesenterium  commune  ileo- 
caecale."  I  once  saw  it,  at  an  early  operation,  strung  up  by  a 
lateral  band  of  connective  tissue,  close  to  the  gall-bladder  behind 
the  liver. 

These  abnormalities  in  the  position  of  gall-bladder  and  appendix 
have  led  to  many  errors  in  diagnosis.    The  following  is  an  instance  : — 

A  female,  aged  40,  was  operated  on  by  an  experienced  surgeon  for 
a  "  perityphlitic  abscess,"  and  she  subsequently  had  a  persistent 
fistula  in  the  ileo-caecal  region.  Two  years  later  she  was  admitted  to 
hospital,  suffering  from  acute  hemiplegia.  She  died  in  a  few  days, 
and  the  autopsy  showed  that  the  fistula,  which  opened  at  the  upper 
part  of  the  inguinal  region,  led  into  the  gall-bladder,  which  contained 
a  large  stone.  The  cystic  duct  was  closed.  The  hemiplegia  was  the 
result  of  a  cerebral  abscess,  in  which  were  found  diplococci  similar  to 
those  in  the  gall-bladder.  Neither  the  surgeon  nor  the  physician  was 
fortunate  in  the  diagnosis  of  this  case,  although  they  were  both 
experienced  observers. 

When  the  inflammatory  process  occurs  above  the  line  joining  the 
anterior  superior  spine  to  the  umbilicus,  we  should  think  of  appendi- 
citis if  the  pain  or  resistance  reach  far  towards  the  side,  and  if  the 
lumbar  muscles  respond  to  pressure,  by  contraction  ;  but  any  in- 
flammatory process  internal  to  the  external  border  of  the  rectus  must 
be  ascribed  to  the  gall-bladder.  If  jaundice  supervenes  in  addition,  the 
beginner  will  immediately  decide  in  favour  of  gall-stones.  This  is 
usually  a  good  guess,  because  the  extension  of  the  inflammatory 
swelling  from  the  gall-bladder  to  the  common  duct  often  leads  to  a 
mild  temporary  jaundice.  But,  on  the  other  hand,  we  often  find  a 
certain  amount  of  jaundice  in  appendicitis,  not  necessarily  in  the 
severest  cases.  If  the  appendix  lies  near  the  gall-bladder,  so  that  the 
biliary  passages  are  secondarily  involved  in  the  inflammation,  the 
jaundice  may  become  very  pronounced. 

A  young  man  was  brought  into  the  hospital  with  a  high  temperature, 
severe  jaundice,  and  abdominal  resistance  reaching  outwards  from  the 
lateral  border  of  the  rectus,  immediately  adjoining  the  liver,  and 
extending  as  far  as  the  crest  of  the  ilium.  Despite  the  jaundice  a 
diagnosis  of  appendicitis  was  made,  based  upon  the  lateral  position  of 
the  resistance.     This  was  confirmed  at  the  operation. 

A  rule  to  the  following  effect  often  enables  a  correct  diagnosis 
to  be  made,  when  the  painful  spot  is  situated  just  on  the  border  line  : 
if  the  dulness  reaches  as  far  as  the  flank,  the  case  is  appendicitis,  but 
if  an  intestinal  note  can  be  elicited  externally  to  the  painful  area, 
cholecystitis  is  present. 

It  is  important  to  make  a  correct  diagnosis.  Early  operation, 
within  the  first  twenty-four  hours,  should  be  proposed  in  appendicitis; 
but  in  cholecystitis  it  is  better  to  wait  until  the  severity  or  the  dura- 
tion of  the  symptoms  demand  interference.     If  the  acute  stage  has 


3l8       SURGICAL   DISEASES   OF   THE   ABDOMINAL   AND   PELVIC   VISCERA 


passed  over  without  any  interference,  the  appendix  should  be  removed 
after  two  or  three  months,  if  the  disease  was  appendicitis;  but,  on  the 
other  hand,  operation  should  be  avoided  if  gall-stones  have  become 
completely  latent.  If  we  still  remain  in  doubt  after  taking  all  physical 
signs  into  consideration,  we  must  be  guided  by  the  rule  that  appendi- 
citis is  more  probable  the  younger  the  patient,  and  gall-stones  the  older 
he  is.  Nevertheless  I  have  twice  seen  girls,  aged  i8,  sent  in  for 
appendicitis,  but  who  were  really  suffering  from  cholecystitis. 

A  special  form  in  which 
1  cholecystitis  may  manifest 
itself  should  be  referred  to. 
Just  as  cases  of  gall-bladder 
inflammation  come  to  the 
surgeon  with  the  diagnosis 
of  appendicitis,  so  do  others 
present  themselves  which 
have  been  diagnosed  as 
"ileus."  Indeed  cholecysti- 
tis may  at  its  beginning  or 
during  its  progress,  cause 
adhesions  between  the  in- 
testine and  gall  -  bladder, 
kinking  or  inflammatory  in- 
filtration of  the  intestinal 
wall,  extensive,  serous  or 
sero  -  purulent  peritonitis, 
which  may  either  produce 
mechanical  obstruction,  or 
the  toxic  symptoms  of  an 
obstruction.  A  correct  dia- 
gnosis can  only  be  made 
from  the  previous  history  of 
the  patient,  and  the  presence 
of  pain  and  resistance,  or  at 
pressure,  in  the  region  of  the 


Left. 

Fig.    149. 
b.    Calcium 
fig-  iSo>  5-) 


Right. 
— fl,  Bismuth  shadow  in  duodenum, 
carbonate     gall  -  stones.       (See    also 


least  of  a   localized 
gall-bladder. 


area    of  pain   on 


(3)   GANGRENOUS    CHOLECYSTITIS. 

In  the  forms  of  gall-bladder  inflammation  so  far  described,  the 
disease  has  been  limited  to  the  gall-bladder  and  its  immediate  vicinity. 
But  if  the  clinical  aspect  is  much  more  severe  and  septic  symptoms 
develop  rapidly,  or  if  an  increased  resistance  follows  upon  a  very  acute 
stage,  we  should  suspect  gangrenous  inflaniniafion  of  the  gall-bladder, 
with  extensive  participation  of  the  peritoneum. 

A  man,  aged  65,  was  suffering  from  severe  inflammatory  symptoms 


SURGICAL   DISEASES   OF   THE   BILIARY   PASSAGES 


319 


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320       SURGICAL   DISEASES   OF   THE   ABDOMINAL   AND    PELVIC   VISCERA 

in  tlie  upper  abdominal  region.  At  first  they  seemed  to  abate,  but 
subsequently  a  diffuse  resistance  developed  in  the  gall-bladder  area, 
with  persistent  high  fever.  Operation  was  performed  at  this  stage, 
and  a  great  cavity  filled  with  offensive  pus  was  encountered,  bounded 
by  the  liver,  stomach,  duodenum  and  large  intestine.  A  shreddy  dark 
grey  membrane,  which  still  preserved  the  shape  of  the  gall-bladder, 
was  hanging  in  the  cavity,  but  it  was  completely  necrotic  and  contained 
a  gall-stone. 

As  in  the  other  form,  juiindicc  is  also  here  merely  an  accessory 
symptom,  which  is  not  essential  to  the  clinical  picture  of  cholecystitis. 
But  if  it  is  present — and  it  is  usually  transitory — we  must  infer  that  a 
phlegmonous  inflammation  has  invaded  the  biliary  passages  from  the 
gall-bladder  and  has  temporarily  arrested  the  free  flow  of  the  bile. 

We  have  hardly  referred  to  the  gall-stones  themselves.  It  is  not 
the  gall-stones  which  we  diagnose,  but  the  inflamniatoiy  changes 
which  their  presence  causes.  We  know  very  well  that  slight  catarrhal 
inflammation  of  the  biliary  passages  often  occurs  after  gastric  and 
intestinal  catarrh,  and  that  very  acute  cholecystitis  may  supervene 
during  the  progress  of  typhoid  fever,  dysentery  and  cholera,  without 
any  formation  of  stones.  But  these  only  account  for  one-tenth  of 
the  cases  of  cholecystitis  which  come  under  observation.  It  follows, 
therefore,  that  a  patient  who  suffers  from  cholecvstitis  without  any 
of  the  antecedent  illnesses  just  mentioned,  most  probably  is  the 
subject  of  gall-stones.  But  it  is  very  regrettable  that  a  purely 
academic  discussion  on  the  matter  should  be  responsible  for  the 
delay  of  a  timely  operation,  and  that  a  stone,  whose  existence  ma}^ 
be  doubtful,  should  eventually  assert  itself  by  gall-stone  obstruc- 
tion and  fatal  intestinal  perforation,  examples  of  which  I  have 
witnessed. 

It  is  a  matter  of  secondary  consideration  whether  the  stone  is  in 
the  gall-bladder  or  in  the  cystic  duct.  In  the  latter  case  there  will 
be  more  acute  exacerbations  of  jaundice  than  if  it  is  situated  in  the 
gall-bladder. 

Many  attempts  have  been  made  to  enlist  the  service  of  skiagraphy 
in  the  diagnosis  of  gall-stones.  But  as  their  main  constituent  is 
cholesterin,  a  substance  which  is  almost  equally  transparent  to  the 
X-rays  as  the  soft  tissues  of  the  human  body,  not  much  is  to  be 
anticipated  from  this  method  of  examination.  Positive  results  have 
only  been  obtained  in  the  very  rare  cases  of  pure  calcium  carbonate 
stones,  and  wnth  cholesterin  stones  which  contain  a  large  amount 
of  calcium  and  magnesium  salts  (or  are  encrusted  therewith)  as  a 
result  of  secondary  infection.  Pigmented  lime  stones,  on  the  other 
hand,  aie  so  loosely  built  up  that  they  cannot  be  detected  in  a 
skiagram.  The  accompanying  figure  (150)  shows  how  a  few  of  the 
most  important  calculi  are  brought  out  on  a  skiagram,  and  fig.  149 
represents  a  calcium  carbonate  stone  revealed  by  skiagraphy  of  the 
living  body  (found  accidentally  after  a  bismuth  meal). 


SURGICAL   DISEASES   OF   THE    BILIARY   PASSAGES  321 

(4)  OBSTRUCTION  OF  THE  COMMON   BILE-DUCT. 

This  presents  a  totally  different  clinical  picture.  Jaundice  i^  the 
predominant  feature  ;  localized  dulness  and  swelling  are  hardly  ever 
present.  The  liver  is  enlarged,  the  urine  contains  much  bile  pigment 
and  the  stools  are  colourless.  These  symptoms  indicate  that  some 
obstruction  exists  in  the  common  duct,  and  we  have  to  determine 
whether  this  is  caused  only  by  a  stone  or  whether  a  malignant  new 
growth  may  be  present.  In  cases  of  stone  the  obstruction  is  not 
merely  caused  by  the  foreign  body,  but  also,  and  to  a  great  extent, 
by  the  accompanying  inflammatory  condition,  and  therefore  the 
biHary  content  of  the  stools  and  the  degree  of  jaundice  are  liable  to 
variations.  But  if  the  obstruction  is  caused  by  carcinoma  there  is  a 
constantly  increasing  mechanical  pressure  exerted  by  the  new  growth, 
and  therefore  the  stools  are  always  free  from  bile  and  the  jaundice 
is  persistent.  If,  in  addition,  we  realize  that  the  pain  is  not  due 
to  congestion  of  the  bile,  but  to  the  inflammatory  process,  we 
will  understand  that  attacks  of  pain  point  to  gall-stones,  whereas 
painless  jaundice  suggests  a  tumour.  These  are  two  fundamental 
differences  between  the  two  conditions.  These  remarks  concerning  the 
attacks  of  pain  apply  equally  well  to  exacerbations  of  high  temperature, 
with  or  without  rigors.  But  we  must  be  on  our  guard  against  diagnos- 
ing gall-stones  merely  because  there  is  a  previous  history  of  biliary 
colic.  In  at  least  five-sixths  of  the  cases  of  cancer  of  the  gall-bladder 
there  has  been  a  previous  history  of  gall-stones.  How,  then,  are  we 
to  make  a  correct  diagnosis  ?  An  example  may  perhaps  indicate  this. 
A  middle-aged  female  suffered  for  many  years  with  regular 
attacks  of  recurrent  gall-stones,  in  testimony  whereof  she  produced 
a  box  full  of  stones  which  she  had  passed  spontaneously.  The  last 
"attack"  was  a  particularly  mild  one,  but  the  jaundice,  which  was 
more  intense  than  on  previous  occasions,  did  not  pass  off  in  the 
usual  manner  ;  indeed,  it  had  persisted  for  several  weeks  unaltered. 
The  general  condition  had  also  suffered  much  more  than  in  previous 
attacks.  These  few  indications  sufficed  to  establish  the  diagnosis  of 
cancer.  The  slight  pain,  but  the  persistent  jaundice,  were  the  cardinal 
symptoms,  and  the  commencing  cachexia  was  corroborative  evidence. 
The  importance  of  jaundice  existing  without  pain  is  shown  by 
the  following  case: — 

An  aged  female  suffered  from  complete  obstruction  of  the  common 
bile-duct,  but  had  no  pain.  A  firm,  somewhat  nodular,  resisting 
mass  could  be  felt  in  the  region  of  the  gall-bladder.  Diagnosis: 
carcinoma.  The  operation  revealed  an  inflamed  gall-bladder,  filled 
with  pus  and  stones,  but  no  cancer.  The  history,  however,  suggested 
very  strongly  that  there  must  be  something  more  present,  and  as  a 
matter  of  fact,  a  deeply-seated  cancer,  which  probably  originated 
in  the  duct,  was  found. 


322       SURGICAL   DISEASES   OF   THE   ABDOMINAL   AND    PELVIC   VISCERA 

Physical  exaniiiintioii,  on  the  whole,  affords  Httle  definite  informa- 
tion. Palpation  is  only  conclusive  if  a  large  irregular  nodular 
tumour  is  found — but  this  is  exceptional.  Nodulated  swellings  which 
do  not  exceed  a  goose's  egg  in  size,  may  be  the  result  of  gall-stones. 

Coiu"voisier's  rule,  if  carefully  applied,  is  very  useful.  If  we  find 
a  tensely  filled  gall-bladder  in  a  case  of  chronic  obstruction  of  the 
common  duct,  w^e  may  conclude  that  the  walls  of  the  gall-bladder 
are  capable  of  being  stretched,  and  therefore  are  not  chronically 
inflamed.  But  as  calculous  obstruction  generally  occurs  after  pro- 
longed suffering  from  cholelithiasis,  that  is  to  say,  after  the  gall- 
bladder has  undergone  chronic  inflammation  and  contraction,  it  fol- 
lows that  a  distended  gall-bladder  contra-indicates  calculous  obstruc- 
tion, and  suggests  the  presence  of  a  new  growth  pressing  upon  the 
common  duct,  but  leaving  the  gall-bladder  itself  free.  On  the  other 
hand,  if  the  gall-bladder  cannot  be  felt,  it  is  an  argument  against 
a  tumour,  and  is  in  favour  of  obstruction  by  a  stone.  This  latter 
conclusion  is,  however,  only  applicable  if  the  tumour  does  not 
originate  in  the  gall-bladder  itself.  Primary  cancer  of  the  gall-bladder 
is  very  frequently  quite  unable  to  be  felt,  or  only  as  a  small  nodular 
swelling  connected  with  an  inflamed  contracted  gall-bladder,  just  as 
in  the  case  of  calculous  obstruction.  On  the  other  hand,  calculous 
obstruction  sometimes  occurs  when  the  gall-bladder  is  still  healthy, 
or  at  least  still  remains  capable  of  distension,  and  then  it  can  be 
felt  on  palpation  just  like  a  congested  gall-bladder  due  to  obstruction 
by  a  growth. 

We  must  always  search  for  sccoiuhiry  deposits  {e.g.,  nodules  on  the 
upper  surface  of  the  liver,  Yirchow-Troisier's  glands  beneath  the 
insertion  of  the  sterno-mastoid),  and  especially  examine  the  abdomen 
for  a  free  effusion.  This  symptom  may  be  conclusive,  even  when 
nothing  else  appears  to  point  to  cancer. 

A  strong  man,  aged  about  40,  who  had  no  previous  history  of 
biliary  disease,  suffered  from  such  severe  pain  of  the  gall-bladder  that 
a  large  amount  of  morphia  had  to  be  prescribed.  A  diagnosis  of  gall- 
stones was  made,  and  this  appeared  to  be  fortified  by  the  presence  of 
jaundice.  But  the  jaundice  persisted,  and  then  a  slight  fluid  effusion 
came  on,  as  the  first  positive  sign  that  the  case  was  one  of  cancer. 
CEdema  of  the  legs  soon  came  on  as  confirmatory  evidence,  and  the 
fatal  result  \vas  not  long  delayed. 

Ascites  occasionally  comes  on  in  cases  of  obstruction  by  stone, 
as  a  result  of  the  secondary  cirrhosis  of  the  liver,  which  is  due  to  the 
biliary  congestion. 

If  the  svmptoms  gradually  and  spontaneously  vanish,  after  we 
have  diagnosed  calculous  obsfructiou,  it  does  not  signify  that  our 
diagnosis  was  wrong,  nor  can  we  be  sure  that  the  stone  has  passed. 
As  soon  as  the  inflammatory  swelling  has  subsided,  the  bile  can  flow^ 
freely  alongside  the  stone,  which  may  remain  latent  in  the  common 
duct.  If  it  still  remains  there,  after  six  to  eight  weeks,  it  should  be 
removed    by  choledochotomy.      The  spontaneous   passage    of   large 


SURGICAL   DISEASES    OF   THE    BILIARY    PASSAGES  323 

stones  into  the  intestine  is  not  usually  effected  per  vias  naturalcs,  but 
through  a  fistulous  opening  between  the  gall-bladder  and  intestine. 

If  we  have  arrived  at  the  diagnosis  of  obstruction  by  tiunour,  we 
must  determine  the  situation  and  origin  of  the  new  growth.  But  this 
is  not  often  possible.  Cancer  of  the  gall-bladder  so  often  runs  its 
course  without  symptoms  until  it  gains  a  great  depth  and  obstructs 
either  the  common  duct  or  the  hepatic  duct,  causing  the  same 
s^^mptoms  as  the  rare  primary  cancer  of  the  common  duct,  or  cancer 
of  the  head  of  the  pancreas.  Palpation  does  not  often  yield  any 
positive  information.  Deficient  digestion  of  fats  would  strongly 
suggest  some  change  in  the  head  of  the  pancreas,  but  it  would  not 
ditferentiate  between  a  new  growth  and  chronic  pancreatitis. 

(5)   HYDROPS  OF  THE  GALL-BLADDER,  CHRONIC 

EMPYEMA. 

Cases  occur,  wherein  a  single  pear-shaped  tense  swelHng  which 
can  be  felt  in  the  gall-bladder  region,  indicates  disease  of  the  biliary 
passages.  If  this  swelling  is  only  slightly  movable,  and  is  somewhat 
tender  on  pressure,  and  there  is  also  a  history  of  inflammatory  attacks, 
the  diagnosis  of  chronic  empyema  of  the  gall-bladder  may  be  made. 
But  if  the  swelling  is  not  tender  on  pressure,  if  it  is  strikingly  mov- 
able, and  the  history  is  negative,  the  diagnosis  can  only  be  hydrops 
of  the  gall-bladder.  The  cause  is  usually  a  small  solitary,  oval,  finely 
lobulated  stone,  incarcerated  in  the  cystic  duct. 

A  young  woman  was  sent  to  be  operated  on  for  an  abdominal 
tumour.  A  tensely  elastic  tumour  of  the  size  of  a  small  fist  was  found 
in  the  upper  part  of  the  abdomen.  It  was  situated  on  the  right  of 
the  spine,  but  it  could  easily  be  pushed  to  the  left,  and  would  remain 
in  the  left  hypochondrium.  On  marking  out  on  the  surface  of  the 
abdomen  the  circuit  of  the  tumour,  the  segment  of  a  circle  was 
described,  whose  mid-point  was  below  the  liver.  This  rendered  some 
connection  with  the  gall-bladder  very  probable.  The  patient  suffered 
no  pain  and  had  no  jaundice,  and  she  had  complained  neither  of  her 
liver  nor  gall-bladder.  Apparently,  the  swelling  was  functionally 
distinct  from  the  biliary  system.  It  was  ascertained  that  the  swelling 
varied  in  size,  but  the  fluctuations  were  not  associated  with  any  pain. 
All  this  pointed  to  hydrops  of  the  gall-bladder.  At  the  operation  the 
contents  were  found  to  consist  of  a  slightly  mucoid,  limpid  fluid,  and 
a  solitary  stone  was  discovered  in  the  C3^stic  duct,  as  anticipated. 

If  a  gall-bladder  affected  with  hydrops  can  be  pushed  towards  the 
right,  more  easily  than  towards  the  middle  line,  it  is  almost  always 
mistaken  for  a  movable  kidney,  even  by  experienced  observers.  The 
difference  can  only  be  established  by  carefully  determining  the  usual 
position  of  the  swelling,  and  the  ease  with  which  it  can  also  be 
moved  towards  the  left.     On  the  other  liand,  a  hydronephrosis  or  a 


324 


SURGICAL   DISEASES    OF   THE   ABDOMINAL   AND   PELVIC   VISCERA 


pyonephrosis  mav  have  grown  so  much  towards  the  middle  hne 
and  to  the  front  that  it  can  be  felt  and  even  seen  in  the  gall-bladder 
area.  Under  these  circumstances,  the  cystoscope  is  required  before 
a  diagnosis  can  be  established. 


(a)  Facetted  stones,  or  large  single 
stone  in  tlie  gall-bladder.  Without  in- 
flammation,  no  symptoms.  With  in- 
/iai//;!iatii}H,cho\ecystki9.,  severe  spon- 
taneous pain  and  also  on  pressure, 
fevers,  rigors  occasionally,  and  vomit 
ing.  Usually  no  jaundice,  stools 
coloured,  urine  clear.  More  or  less 
rapid  subsidence,  or  transition  to 
chronic  empyema. 

((^)  Solitary  stone  in  cystic  duct, 
oval,  generally  wedged  in  firmly. 
IVithout  pronounced  injiainniation, 
hydrops  of  gall-bladder,  no  jaundice, 
stools  coloured,  urine  clear,  no  pain. 
With  inflaviination,  empyema  of  gall- 
bladder, symptoms  of  cholecystitis  as 
in  a,  but  gall-bladder  larger,  and 
jaundice  somewhat  more  frequent. 

(c)  Stone  in  upper  part  of  common 
duct.  Without  inflammation,  little  or 
no  pain.  With  inflammation,  obstruc- 
tion of  common  duct  of  varying  de- 
gree, jaundice,  pruritus,  urine  brown. 
Stools  yellowish  or  greyish-white. 
Liver  enlarged,  gall-bladder  unusually 
small,  pancreatic  digestion  normal. 
Frequent  attacks  of  pain,  high  tem- 
perature, rigors.  Ascites  in  the  later 
stages. 

((/)  Obslruction  in  upper  part  of 
common  duct,  due  to  a  tumour  (cancer 
of  gall-bladder,  cystic  duct  or  comnion 
duct).  Persistent  severe  jaundice, 
pruritus,  urine  brown,  stools  constantly 
grey.  Attacks  of  pain,  high  tempera- 
ture and  rigors  usually  absent.  Early 
ascites,  pancreatic  digestion  normal. 

{e)  Obstruction  by  stone  in  lower 
part  of  common  duct.  Witlwut  in- 
flammation, no  pain  or  indefinite. 
With  inflammation,  as  at  c,  but  jaun- 
dice more  persistent.  Occasionally 
disturbance  of  pancreatic  digestion. 

(y)  Obstruction  by  tumour  at  lower 
part  of  common  duct.  (Cancer,  more 
rarely  chronic  inflammation  of  head  of 
pancreas,  cancer  of  duodenum),  as  at 
d,  but  generally  disturbance  of  pan- 
creatic digestion. 

(g)  Amorphous  calcium  bilirubin 
concretions  in  the  biliary  duct.  Not 
recognizable  clinically.  Cause,  so- 
called  genuine  stone  diathesis. 


Fig.  151. — General  diagrammatic  view  of  the  forms  of 
obstruction  of  the  biliary  passages. 


(6)  ACUTE  CHOLANGITIS. 

Some  cases  of  incarceration  of  stone  in  the  common  duct,  or  of 
acute  infective  disease  (typhoid,  cholera,  pneumococcic  infection)  are 
followed  by  an  intensely  septic  state,  and  there  supervenes  a  clinical 
picture  of  rigors,  with  high  fever  and  jaundice.  This  indicates  an 
acute  cholangitis,  which  is  caused  by  an  ascending  infection  in 
gall-stone  disease,  and  as  a  blood  infection  in  the  disease  just 
mentioned. 

We  assume  that  there  is  passive  congestion  of  the  bile  when  the 
faeces  are  colourless  and  the  urine  contains  bilirubin,  and  that  the 
jaundice  is  due  to  damage  to  the  liver  cells,  when  the  faeces  remain 
coloured  and  the  urine  contains  urobilin  in  addition,  or  alone. 


TUMOURS   OF   THE    LIVER  325 

CHAPTER  XLII. 
TUMOURS  OF  THE   LIVER. 

It  has  happened  that — on  casual  examination — a  movable  liver 
has  been  mistaken  for  an  abdominal  tumour.  Careful  examination 
will,  of  course,  show  that  the  liver  is  absent  from  its  normal  position, 
and  that  therefore  the  structure  felt  in  the  mid-abdominal  region  must 
be  this  missing  organ.  It  is  only  necessary  to  place  the  patient  in  a 
posture  wherein  the  thorax  is  lowered  to  observe  that  the  liver  resumes 
its  normal  situation.  It  may  also  happen  that  a  liver,  which  is  not 
especially  movable,  is  pushed  so  far  downwards  by  an  extensive 
right  pleural  effusion  that  palpation  suggests,  for  the  moment,  that  an 
abdominal  tumour  is  really  present.  Such  an  error  is  more  conceiv- 
able in  cases  of  a  constricted  lobule  of  the  liver,  especially  if,  owing 
to  an  aberration  of  the  sense  of  beauty,  the  patient  has  undertaken  self- 
treatment  of  the  constriction,  and  has  thus  produced  various  derange- 
ments of  digestion.  The  diagnosis  is  usually  easy,  and  is  indicated  by 
the  unnatural  waist-like  constricting  furrow,  which  is  visible  on  the 
skin,  and  by  the  fact  that  the  lobule,  which  is  felt,  is  connected  with  the 
liver.  If  the  lobule  is  very  movable,  it  is  easily  mistaken  for  a  mov- 
able kidney,  especially  as  it  can  sometimes  be  displaced  into  the  renal 
region. 

As  a  rule,  it  is  quite  easy  to  decide  on  careful  examination  whether 
a  tumour-like  structure  is  connected  with  the  liver.  If  the  tumour 
projects  far  downwards,  the  transverse  colon  may  lie  over  it,  and  on 
percussion  a  zone  of  intestinal  note  will  appear  to  separate  it  from  the 
liver.  The  condition  can,  however,  be  cleared  up,  by  examining  the 
patient  in  varving  states  of  intestinal  fulness,  or  after  artificial  emptying 
of  the  colon.  Tumours  of  the  liver  are  sometimes  simulated  by  large 
cancers  of  the  stomach  and  occasionally  by  renal  tumours  which  have 
grown  forward. 

Let  us  assume  a  case  in  which  there  is  a  localized  tumour-like 
structure  in  a  liver,  which  is  not  otherwise  enlarged.  The  most  pro- 
bable diagnosis  is  a  secondary  malignant  growth,  and  this  view 
would  be  confirmed  by  a  history  of  general  malaise  and  wasting  for 
some  considerable  period  before  the  appearance  of  the  tumour,  or  by 
the  presence  of  several  nodules.  We  may  only  assume  that  the  case 
is  one  of  primary  growth  of  the  liver,  if  an  exhaustive  examination 
has  failed  to  reveal  an  original  focus. 

It  is  not  possible  to  definitely  distinguish  between  an  innocent  and 
malignant  growth,  before  the  onset  of  jaundice  and  cachexia.  If  it 
is  possible  to  feel  through  the  abdominal  wall  that  the  tumour  is 
round  in  form  and  soft  in  consistence,  it  would  suggest  an  innocent 
growth,  cyst  or  cavernous  angioma.     But   if  the  tumour  is  nodular. 


326      SURGICAL    DISEASES    OF   THE    ABDOMIXAL    AND    PELVIC    VISCERA 

or  if  umbilication  is  detected,  which  is  quite  possible  in  thin  subjects, 
then  it  is  ahnost  certainly  malignant — cancer.  But  a  gumma  of  the 
liver  may  closely  resemble  a  tumour,  and  thus  lead  to  errors  ;  therefore 
the  serum  test  and  specific  treatment  are  indicated  in  all  doubtful 
tumours  of  the  liver. 

If  the  patient  is  jaundiced  the  question  of  malignancv  is  settled, 
and  therewith  also  the  uselessness  of  surgical  intervention.  If  there 
are  multiple  growths  in  the  liver  we  are  justified  in  concluding  that 
they  are  of  a  secondary  metastatic  nature,  and  therefore  that  they  are 
malignant.  The  former  conclusion  is,  however,  not  always  accurate. 
There  are  primary  adenomata  of  the  liver,  which  are  multiple  and 
which  permeate  the  whole  organ  with  large  nodules.  These  are 
usually  accompanied  by  jaundice,  and  they  behave  clinically  like 
malignant  growths.  Cysts  which  are  quite  innocent  mav  also  be 
present  in  some  number. 

This  leads  us  to  cystic  tumours  of  the  liver.  If  we  find,  in  imme- 
diate connection  with  the  liver,  a  structure  which  by  its  size,  round- 
ness of  form,  and  soft  elasticity  of  consistence,  declares  itself  to  be  a 
cyst,  we  should  not  abandon  further  investigation  and  proceed  to  an 
exploratory  puncture,  in  order  to  decide  whether  it  is  an  abscess,  a 
hydatid  or  some  other  cyst.  The  puncture  will  probably  shed  no 
new  light  on  the  diagnosis  and  may  kill  the  patient.  However  fine 
the  trocar,  the  fluid,  if  under  pressure,  and  if  the  cyst  is  suppurating, 
may  infect  the  peritoneum.  Death  has  also  followed  rapidly,  from 
the  absorption  of  non-infected  hydatid  fluid.  We  must,  therefore, 
endeavour  to  arrive  at  a  diagnosis  by  other  means.  An  example  will 
illustrate  the  method. 

A  young  man  came  from  Bulgaria  to  our  neighbourhood,  which  is 
free  from  hydatid  disease.  After  four  years'  residence  a  tumour 
appeared  in  the  hepatic  region.  The  patient  incidentally  told  the 
doctor  that  he  had  noticed  a  sudden  onset  of  urticaria  after  a  blow 
sustained  over  the  tumour.  The  doctor  argued  as  follows  :  Dogs  play 
a  much  greater  part  in  the  life  of  Bulgaria  than  they  do  among  us  ; 
therefore  there  is  a  greater  probability  of  echinococcus  infection.  The 
blow  over  the  tumour  may  have  led  to  the  absorption  of  some  of  its 
contents,  and  experience  shows  that  a  fluid  whose  absorption  causes 
urticaria  is  hydatid  fluid  ;  therefore  the  tumour  must  be  a  hydatid  cyst. 
The  operation  confirmed  this  conclusion. 

Urticaria  is  indeed  a  very  significant  sign  of  absorption  of  hydatid 
fluid.  But  if  no  such  indication  is  present,  and  the  neighbourhood  is 
free  from  echinococci,  there  is  no  other  course  to  pursue  but  that 
of  exploratory  laparotomy.  Sometimes  it  remains  for  the  pathological 
anatomist  to  make  a  definite  diagnosis. 

As  we  are  on  the  subject  of  hydatids  we  must  mention  the  rare  form 
of  niiiltilocular  hydatid,  which  hitherto  has  only  been  diagnosed 
post  niortein.     If  a  patient  is  suffering  from  an  unusual  enlargement  of 


SURGERY  OF  THE  PANCREAS  327 

the  liver,  accompanied  by  more  or  less  pronounced  jaundice,  which 
even  in  the  course  of  years  causes  no  deterioration  in  the  general 
health,  the  possibility  of  this  variety  of  hydatid  should,  at  least,  occur 
to  us.  There  can  be  very  little  doubt  about  it,  if  the  patient's  habits 
have  brought  him  into  close  contact  with  dogs,  and  if  the  enlargement 
of  the  liver  no  longer  resembles  in  shape  and  size  that  of  hypertrophic 
cirrhosis,  for  which  a  multilocular  hydatid  is  most  likely  to  be 
mistaken. 

But  if  there  is  no  indication  of  hydatids,  and,  on  the  other  hand, 
the  patient  has  lived  in  the  Tropics,  or  has  suffered  from  gall-stones, 
we  sliould  think  of  abscess  of  the  liver.  This  assumption  is  con- 
firmed by  intermittent  or  remittent  high  temperature,  by  rigors,  pain 
in  the  right  shoulder,  pleuritic  symptoms  and  increasing  cachexia. 
The  absence  of  these  symptoms,  however,  need  not  make  us  discard 
the  diagnosis  of  abscess.  Liver  abscesses  may  exist  for  a  very  con- 
siderable time  without  fever,  so  that  the  local  swelling,  the  localized 
pain  and  the  etiology  must  suffice  to  indicate  the  nature  of  the  malady. 
But  if  these  local  signs  are  also  absent,  because  of  the  deep  situation 
of  the  abscess,  the  diagnosis  is  quite  impossible  and  the  condition  may 
remain  undetected  for  months. 

A  chronic  hepatic  abscess,  in  these  latitudes,  is  very  likely  to  be 
mistaken  for  cancer,  because  this  latter  is  a  much  more  frequent 
sequel  of  cholelithiasis  than  is  a  solitary  abscess.  In  doubtful  cases, 
an  exploratory  incision  is  advisable,  because  this  may  lead  to  the  cure 
of  an  abscess  and  can  do  no  harm  in  the  case  of  cancer. 

If  a  fluctuating  swelling  is  found,  in  the  absence  of  any  history 
supporting  either  a  hydatid  or  an  abscess,  we  must  assume  that  it  is 
one  of  the  rare  forms  of  non-parasitic  liver  cyst  (dermoid,  ciliated 
cyst,  cystic  adenoma),  the  nature  of  which  can  only  be  ascertained 
by  microscopic  examination. 


CHAPTER   XLIIl. 
SURGERY    OF   THE    PANCREAS. 

We  have  already  mentioned  that  the  whole  of  the  pancreas  can 
sometimes  be  felt  in  thin  people,  with  enteroptosis.  This  is  a  fact 
of  importance,  for  the  inexperienced  are  liable  to  mistake  such  a 
pancreas  for  a  pathological  structure.  Diseases  of  the  pancreas  are 
not  frequent,  but  those  which  can  be  diagnosed  with  reasonable 
probability  are  among  the  rarest  incidents  of  surgical  practice.  We 
shall,  therefore,  deal  with  them  briefly. 

The  symptomatology  of  these  diseases  may  be  classed  under  three 
headings  : — 


328      SURGICAL   DISEASES    OF   THE   ABDO:\IIXAL   AXD    PELVIC    VISCERA 

(1)  ACUTE  PANCREATITIS  AND  PANCREATIC 
H/EMORRHAGE. 

If  ail  individual — generally  a  male  of  advancing  years — is  attacked 
by  symptoms  which  resemble  either  acute  peritonitis  or  intestinal 
obstruction,  often  after  suffering  some  indefinite  prodromal  intestinal 
discomfort,  and  if  these  symptoms  are  mainly  localized  in  the  upper 
abdominal  region,  we  are  justified  in  thinking  of  the  possibility  of 
pancreatic  haemorrhage  or  acute  pancreatitis.  This  assumption  is 
not  negatived  by  slight  jaundice,  l^ut  it  is  supported  by  an  early 
acceleration  of  the  pulse  and  a  lowering  of  the  blood-pressure.  If 
the  initial,  spontaneous  and  pressuie  pain  is  especially  pronounced 
in  the  upper  abdominal  region,  and  if,  after  the  cessation  of  the 
muscular  rigidity,  a  diffuse  resistance  is  appreciable  in  the  epigastrium, 
the  assumption  becomes  a  probability.  The  rapid  loss  of  strength 
and  enfeeblement  of  the  pulse,  the  early  onset  of  low  delirium  and 
the  possibility  of  evacuating  gas  by  means  of  enemata,  without  re- 
lieving the  patient  or  causing  the  vomiting  to  abale,  are  points  against 
ileus.  The  absence  of  generalized  abdominal  rigidity  and  the  early 
onset  of  meteorism  are  points  against  acute  perforation  of  the 
stomach,  although  the  seizure  of  pain  may  be  just  as  sudden  as  in 
perforation.  It  may  be  some  consolation  for  the  practitioner  who 
makes  his  diagnosis  at  the  autopsy,  to  know  that  Germany's  greatest 
surgeon  recently  succumbed  to  acute  panci'eatitis  without  anyone 
even  suspecting  the  possibility  of  this  condition.  These  diseases 
appear  to  be  more  frequent  in  some  districts  than  in  others.  The 
fact  that  the  cases  sometimes  come  on  as  a  result  of  cholelithiasis  is 
not  of  much  help  to  diagnosis,  because  any  recurrence  of  disease  in 
such  patients  would  naturally  be  ascribed  to  an  acute  exacerbation  of 
the  old  trouble. 

Although  the  diagnosis  can,  as  a  rule,  only  be  suspected  or 
regarded  as  probable,  nevertheless,  the  relationship  between  this 
disease  and  biliary  disease  does  permit  a  more  definite  conclusion  to 
be  arrived  at  in  certain  cases.     For  example  : — 

A  stout  female  patient,  aged  50,  was  recovering  from  mild 
jaundice,  associated  with  a  gall-stone  attack,  when  she  was  suddenly 
seized  with  severe  pain  in  the  upper  abdomen,  accompanied  by 
collapse  and  followed  by  vomiting,  retention  of  flatus  and  slight 
meteorism.  In  the  course  of  the  next  twenty-four  hours  there  was 
definitely  increased  dulness  in  both  flanks.  The  pulse  was  rapid  and 
soft.  The  pain  was  localized  to  the  left  of  the  middle  line,  thus  con- 
trasting with  the  pain  of  biliary  colic.  There  were  two  possibilities  ; 
either  perforation  of  the  gall-bladder  or  acute  pancreatitis.  The 
position  of  the  pain  favoured  pancreatitis,  and  this  diagnosis  was 
confirmed  by  the  operation,  which  was  performed  forthwith. 

In  the  rare  cases  wherein  a  patient  withstands  an  acute  attack  of 


SURGERY  OF  THE  PANCREAS  329 

pancreatitis,  and  a  localized  collection  of  pus  follows  in  the  upper 
abdomen,  we  may  confidently  diagnose  pancreatic  suppuration, 
provided  there  is  no  reason  to  assume  ulcerative  perigastritis.  The 
presence  of  glycosuria  is  of  great  diagnostic  importance  in  these 
cases,  but  this  condition  is  only  found  if  the  entire  gland  is  destroyed. 
Cammidge's  pancreatic  reaction  of  the  urine  has  hitherto  not 
proved  of  much  practical  value  in  these  diseases,  because  this  test  is 
not  specific  and  requires  an  experienced  chemist  with  a  chemical 
laboratory.  Neither  is  the  examination  of  the  stools  for  trypsin  of 
clinical  value.  The  presence  of  fat  in  the  stools  is  only  of  significance 
when  the  bile  is  normal. 


(2)  CHRONIC  PANCREATITIS:  CANCER  OF  THE  HEAD  OF 
THE  PANCREAS:  PANCREATIC  CALCULUS. 

In  a  case  of  persistent  jaundice,  with  stools  which  show  a  deficient 
absorption  of  fat  and  digestion  of  meat,  and  wherein  there  is  also  a 
very  dilated  gall-bladder,  we  are  justified  in  thinking  of  some  morbid 
change  which  is  simultaneously  obstructing  the  common  bile-duct 
and  the  pancreatic  duct. 

If,  in  addition,  a  resistance  can  be  felt  in  the  epigastrium  on  the 
right,  close  to  the  spine,  we  may  assume  that  the  head  of  the  pancreas 
is  diseased.  But  we  cannot  tell  from  the  clinical  symptoms  whether 
the  disease  is  cancer,  chronic  interstitial  injianiniation,  or  a  pancreatic 
stone.  We  cannot  tell  definitely  whether  it  may  not  be  a  cancer  of 
the  common  duct  or  of  the  duodenum,  which  is  resembling  disease 
of  the  head  of  the  pancreas.  It  is  sometimes  very  difficult  or  even 
impossible  to  make  an  accurate  diagnosis,  even  at  the  operation. 

Chronic  interstitial  inflammation  may  result  from  a  gall-stone  in 
the  papilla  of  Vater  as  well  as  from  a  pancreatic  stone.  But  it  may 
also  be  of  a  specific  nature — syphilis  more  frequently  than  tubercle. 
Chronic,  sub-acute  suppuration,  or  even  gangrene,  of  the  pancreas 
may  occur  owing  to  the  presence  of  stones.  If  one  thinks  of  this 
possibility  in  any  given  case,  the  diagnosis  might  be  confirmed  by 
a  skiagram,  as  these  stones  mainly  consist  of  calcium  carbonate, 
otherwise  it  will  be  made,  for  the  first  time,  at  the  operation. 

(3)   PANCREATIC  TUMOURS  AND  CYSTS. 

A  localized  tumour  in  the  mid-line  of  the  epigastrium,  betw^een 
the  stomach  and  transverse  colon,  but  which  can  be  shown  to  be 
independent  of  these  organs  by  distending  them  with  air,  and  which 
does  not  give  rise  to  jaundice  or  any  other  striking  symptom,  suggests 
a  pancreatic  tumour  which  does  not  involve  the  head  of  that  viscus. 
If  the  structure  is  not  very  large,  but  is  firm  or  nodular,  it  is  probably 
a  malignant  growth.     But  if  it  is  larger  and  rounder,  and  more  or 


330       SURGICAL   DISEASES   OF   THE   ABDOMINAL   AND    PELVIC    VISCERA 

less  tensely  elastic  in  consistence,  it  is  a  cyst.  One  cannot  be  quite 
sure  that  it  arises  in  the  pancreas,  because  there  are  other  retro- 
peritoneal cysts,  such  as  dermoids  and  hydatids.  A  cyst  may  still  be 
of  pancreatic  origin,  even  if  it  appears  above  the  stomach,  or  below 
the  colon. 

A  positive  diagnosis  can  only  be  made  by  means  of  an  exploratory 
puncture,  but  this  is  as  inadvisable  here  as  in  other  abdominal  cysts. 


CHAPTER    XLIV. 
SURGERY  OF  THE   SPLEEN. 

The  spleen  exemplifies  especiallv  well  the  pi"esent-day  border  line 
between  medicine  and  suigerv.  The  surgeon  is  left  in  undisputed 
possession  of  abscesses,  genume  tumours  and  hydatids  ;  but  certain 
forms  of  splenic  hypertrophy  are  still  the  subject  of  controversy. 

(1)  ABSCESS  OF  THE  SPLEEN. 

The  previous  remarks  concerning  abscess  of  the  liver  also  apply 
to  splenic  abscess  :  its  course  mav  be  quite  free  from  symptoms,  and 
remain  unrecognized  until  it  bursts  into  a  neighbouring  organ.  If  it 
is  attended  b}^  symptoms,  they  consist  of  enlargement  of  the  organ, 
pain  on  pressure,  and  also  spontaneous  pain,  in  the  left  hypo- 
chondrium.  But  another  consideration  is  necessary  before  we  can 
make  a  diagnosis,  viz.,  the  etiology,  because  splenic  abscesses  are  apt 
to  occur  after  typhoid  fever,  intermittent  fever,  or  any  pyjemic  disease. 
But  as  the  spleen  so  frequently  enlarges  in  these  conditions,  we  must 
not  assume  the  presence  of  an  abscess,  unless  the  enlargement  is 
greater  than  usual,  and  increases  rather  than  diminishes  after  the 
subsidence  of  the  original  disease.  Inflammatory  symptoms  in  the 
vicinity,  such  as  left-sided  pleurisy  and  oedema  of  the  anterior  or 
lateral  wall  of  the  abdomen,  are  points  in  favour  of  the  diagnosis. 
Puncture  is  as  inadvisable  here  as  in  hepatic  abscess,  unless  one  is 
prepared  for  immediate  operative  treatment  of  the  abscess. 

(2)  SPLENIC  HYPERTROPHY. 

The  diagnosis  of  the  various  forms  of  diffuse  enlargement  of  the 
spleen  must  be  shared  with  the  physician.  He  justly  claims  all 
enlargements  due  to  circulatory  disturbance,  as  congested  spleen,  the 


SURGERY    OF   THE    SPLEEN 


33^ 


splenic  enlargement  of  hepatic  cirrhosis  and  the  various  forms  due 
to  portal  obstruction.  There  is  no  surgical  treatment  for  these,  unless 
an  attempt  is  made  by  means  of  Talma's  operation.  The  splenic 
hypertrophy  in  all  these  cases  is  secondary  to  some  other  condition. 
Surgery  is  equally  ineffectual  when  the  hypertrophy  is  associated  with 
a  blood  or  lymph  disease,  such  as  leukaemia,  pseudoleukaemia,  or 
polycythcemia.  Enormous  leuka^mic  spleens  have  been  removed, 
but  the  results  have  invariably  been  fatal.  Baiiti's  disease  forms  an 
exception,  but  we  do  not  know  whether  this  is  a  disease  sui generis,  and 
how  it  should  be  classified.  Extirpation  of  the  spleen  has  benefited 
some  cases,  although  the  hepatic  condition  associated  with  it  seems 
to  play  an  important  part.  The  diagnosis  can  be  made,  if  the  malady 
has  started  with  splenic  enlargement  and  has  been  followed  by  slight 
jaundice,  bile  in  the  urine  and  cirrhosis  of  the  liver. 

Infective  and  toxic  eidargenicnts  of  tlie  spleen  {congenital  syphilis  and 
anixloid  disease)  cannot  be  influenced  by  surgery.  The  malarial 
spleen  forms  an  exception,  for  I  have  myself  seen  its  removal  followed 
by  an  unexpected  recovery  from  a  severe  malarial  cachexia.  The 
diagnosis  of  a  malarial  spleen  is  not  difficult,  if  we  remember  its 
tendency  tov/ards  downward  displacement.  It  can  always  be  recog- 
nized by  its  sharp  edge,  even  if  it  has  sunk  over  to  the  right  side. 
I  have,  however,  seen  a  malarial  spleen  sent  in  for  operation  as  an 
ovarian  tumour,  because  its  lower  end  was  adherent  in  the  true  pelvis. 

(3)  TUMOURS  OF  THE  SPLEEN. 

If  the  splenic  region  is  occupied  by  an  irregular  tumour  which 
does  not  conform  to  the  shape  of  the  spleen  at  all,  or  only  does  so 
indefinitely,  we  are  justified  in  thinking  of  a  new  growth,  usually, 
as  experience  shows,  a  sarcoma.  The  confusion  with  a  renal  tumour 
may  be  avoided  by  remembering  that  the  spleen  can  always  be  felt 
more  definitely  in  front,  while  the  kidneys  are  better  felt  from  behind. 
This  applies  to  the  rare  sevens  cysts  of  the  spleen  and  to  hydatids,  which 
are  also  not  very  frequent. 

A  pronounced  splenic  tumour  in  a  tubercular  subject  should 
suggest  the  possibility  of  a  tubercular  spleen,  a  condition  in  which 
surgery  has  effected  some  useful  results. 


22 


332      SURGICAL   DISEASES   OF   THE   ABDOMINAL   AND    PELVIC   VISCERA 

CHAPTER    XLV. 
ACUTE   APPENDICITIS. 

We  have  already  seen  in  Chapter  XXXVI  how  to  recognize  appen- 
dicitis, and  to  avoid  the  numerous  diagnostic  errors  which  mav  attend 
it.  It  now  remains  to  determine  what  physical  examination  can  teach 
us  about  the  condition  of  the  appendix  and  its  snrroiindings.  We  shall 
confine  ourselves  to  those  facts  which  are  recognizable  with  ease,  and 
W'hich  are  impcM'tant  in  treatment.  As  long  as  one  is  quite  clear  about 
these,  no  blame  will  attach  to  him  if  he  is  in  doubt  about  details  of 
pathological  processes  in  the  appendix. 

These  chief  points  range  themselves  around  the  following  four 
questions  : — 

(i)  Is  the  inftaiuniation  limited  to  the  appendix  and  its  hnniedlatc 
neighbourhood,  or  has  It  already  extended  beyond  '! 

We  purposely  sav  "  and  its  immediate  neighbourhood  "  because 
as  long  as  the  inflammation  is  exclusively  confined  to  the  appendix 
the  clinical  signs  of  an  "  attack  "  cannot  have  appeared.  These  only 
arise  at  the  moment  when  the  inflammation  involves  the  neighbouring 
serous  surface.  This  condition  represents  what  is  usually  termed  the 
early  stage.  The  peritoneum  is  slightly  reddened,  and  some  fibrin  is 
sometimes  already  found  on  the  appendix.  The  abdominal  cavity 
contains  some  early  exudation   in  most  cases. 

In  exceptional  cases  this  early  exudation  is  purely  serous,  but  as 
a  rule  it  contains  a  number  of  polynuclear  leucocytes  from  the  start. 
It  differs  from  the  infective  exudate  of  appendicular  peritonitis  proper, 
by  its  homogeneous  appearance  and  its  freedom  from  smell.  It  is 
also  usuallv  free  from  bacteria,  on  the  first  day,  but  from  the  second 
day  it  is  more  or  less  crowded  with  micro-organisms.  On  the  other 
hand,  the  exudate  of  a  fully  developed  purulent  peritonitis  usually 
has  an  evil  odour,  contains  a  large  number  of  micro-organisms,  and 
— in  the  worst  cases — only  a  few  leucocytes.  It  is  also  distinguished 
from  the  harmless  early  exudate  by  its  less  homogeneous  appearance 
to  the  naked  eye. 

One  is  tempted  to  diagnose  this  early  stage  from  the  circumstance 
that  the  attack  has  come  on  within  the  last  twenty-four  hours.  This 
would  no  doubt  be  true  in  most  cases,  but  not  in  all,  for  we  some- 
times find  signs  of  severe  infection  at  the  end  of  the  first  day,  and 
even  pus  about  the  appendix.  On  the  other  hand,  the  disease  may 
remain  in  the  first  stage  for  a  considerable  time,  so  that  an  "early" 
operation  can  be  done  after  several  days  without  any  danger.  The 
decisive  point  does  not  lie  with  the  element  of  time,  but  with  the 
result  of  ph3^sical  examination.     We   must   consider  that  the  patient 


ACUTE   APPENDICITIS 


333 


is  still  within  the  first  stage  of  his  attack  if  the  upper  half  of  the 
abdomen  and  the  left  side  are  still  soft  and  not  tender,  if  there  is  no  pain 
in  the  lumbar  regions,  at  any  rate  the  left,  and  if  tlie  pain  on  pressure 
and  localized  reflex  contraction  are  limited  to  the  suspected  site  of  the 
appendix  without  any  extensive  dnlness  or  definite  resistance  (fig.  143,  a). 
It  is  always  wrong,  and  frequently  dangerous  to  assume  that  the  early 
stage  lasts  forty-eight  hours. 

If  we  see  the  patient  in  what  is  really  the  early  stage,  it  is  our 
duty  to  propose  an  immediate  operation,  which  then  has  every 
prospect  of  being  a  radical  procedure. 

If  in  spite  of  this  advice  the  patient  decides  to  accept  the  risk  of 
a  fully-developed  attack  of  appendicitis,  we  can  at  least  sa}^,  "  Disci 
et  salvavi  aniniam  meaui."  But  we  must  be  absolutely  sure  of  our 
diagnosis  in  order  to  advise  operation  with  a  good  conscience.  The 
removal  of  an  appendix  in  hysteria,  muco-membranous  colitis, 
typhoid  fever,  or  even  in  pneumonia,  does  not  redound  to  the 
credit  of  surgery. 

(2)  Is  an  inflammation  ivliicli  has  gone  beyond  the  first  stage 
localized  or  generalized  f 

If  the  disease  has  extended  beyond  the  first  stage  of  strictly 
limited  appendicular  inflammation,  and  of  early  aseptic  exudation, 
confined  to  the  immediate  vicinity,  we  have  to  decide  how^  far  the 
inflammatory  process  has  travelled.  //  the  abdomen  is  everywhere 
sensitive  to  light  percussion,  if  pressure  on  tlie  lumbar  regions  elicits  pain, 
and  if  palpation  produces  extensive  reflex  muscular  contraction,  it  is 
quite  certain  that  there  is  considerable  involvement  of  tlie  peritoneum, 
even  if  there  is  no  duluess  to  be  detected  in  tlie  dependent  parts.  But 
if  we  can  demonstrate  an  area  of  resistance  which  is  sensitive  to  pressure, 
didl,  or  highly  tympanitic  on  percussion,  whereas  the  rest  of  the  abdomen 
is  comparatively  soft,  not  at  all  or  only  slightly  distended,  and  not 
sensitive  to  pressure,  tlien  the  process  before  us  is  a  localized  one.  This 
localized  process  probably  represents  a  fibrinous  or  fibrino-purulent 
inflammation  of  the  neighbouring  intestinal  coils  in  those  cases 
wherein  the  symptoms  abate  in  a  lew  days  ;  and  in  those  wherein 
the  resistance  persists  for  three  or  four  days,  or  actually  increases, 
it  means  a  definite  abscess. 

(3)  Upon  what  does  a  general  involvement  oj  tlie  peritoneum  depend  f 
In  regard  to  this  we  must   distinguish   two   conditions  which   are 

quite  separable  clinically,  in  typical  cases.  The  case  may  be  one  of 
simple  "early  exudation,"  which  will  subside  after  the  inflammatory 
area  has  become  encapsuled. 

This  diagnosis  should  be  made  if  the  attack  is  at  its  commencement, 
ivith  pidse  and  temperature  incorrect  relation  to  each  oilier,  if  tlie  patient 
does  -not  look  very  septic,  if  the  muscular  rigiditv  is  neither  severe  nor 
very  extensive,  ami  if  the  vomiting  has  ceased  on  the  second  day. 


334      SURGICAL   DISEASES    OF   THE   ABDOMINAL   AXD    PELVIC   VISCERA 

The  generalized  inflammation  may,  on  the  other  hand,  depend 
upon  an  initial  severely  septic  infection  of  the  whole  peritoneum. 
This  is  usually  due  to  acute  gangrene  of  the  appendix,  or  to  an 
extensive  perforation  which  has  flooded  the  peritoneal  cavity  with 
septic  material.  The  exudation  is  very  septic  from  the  start,  and^ 
indeed,  contains  more  bacteria  than  leucocytes.  We  base  this 
diagnosis  on  the  presence  of  pallor,  cyanosis,  rapid  tlircad-like  pnlse, 
normal  or  snhnornial  temperature  in  tlie  extremities  and  in  tlie  axilla, 
hut  a  IiigJi  rectal  temperature,  dry  tongue,  and  on  semi-conscioiisiiess 
supervening  on  the  second  or  third  day  (fig.  143,  /.).  If  these  symptoms 
should  appear  during  the  later  course  of  the  disease,  it  means 
probably  that  an  abscess  which  had  been  originally  localized  has 
burst  into  the  abdominal  cavity.  In  these  cases  it  is  still  generally 
possible  to  discover  the  site  of  the  original  localized  inflammation. 

The  cases  of  sero-purulent  peritonitis  are  intermediate  between  those 
with  mild,  sterile,  or  slightly  infective  early  exudation  and  those  of 
severe  septic  peritonitis.  Their  diffuse  symptoms  of  inflammation 
generallv  abate  during  the  first  week,  but  they  leave  infective  germs 
in  various  portions  of  the  abdominal  wall,  w"hich  are  partially  absorbed, 
but  which  also  lead  to  the  formation  of  localized  abscesses — so-called 
residual  abscesses — in  the  course  of  two  or  three  weeks. 

The  differentiation  of  these  various  forms  of  general  peritonitis  is 
not  merely  of  theoretical  interest,  but  has  important  therapeutic 
bearings.  If  we  or  the  patient  have  allowed  the  opportunity  of  an 
early  operation  to  slip  by,  and  the  case  is  in  the  stage  of  early  exuda- 
tion of  mild  character,  we  need  not  be  anxious,  but  may  await  its 
subsidence  with  a  clear  conscience,  and  anticipate  the  localization 
of  the  process.  But  if  a  diagnosis  of  dift\ise  septic  peritonitis  has 
been  made,  the  abdomen  must  at  once  be  opened  in  several  places — 
it  must  be  washed  out  and  thoroughlv  drained  as  circumstances 
demand.  The  vounger  the  patient,  the  more  likely  is  the  issue  to  be 
successful.  It  is  more  difficult  to  recognize  the  intermediate  forms, 
which  often  enough  develop  mto  localized  abscesses  even  without 
our  intervention.  But,  nevertheless,  it  is  better  to  open  the  abdomen 
in  the  middle  line  and  m  the  loins,  in  order  to  wash  it  out  and 
provide  free  drainage.  This  small  procedure  will  often  succeed  in 
tiding  the  patient  over  a  critical  period — if  combined  with  the  appli- 
cation of  warm  compresses,  subcutaneous  and  rectal  infusions  and 
the  administration  of  stimulants. 

Immediate  operation  must  be  undertaken  if  a  fresh  attack  of  acute 
general  peritonitis  starts  from  a  localized  area  after  the  subsidence  of 
the  origmal  dift'use  symptoms. 

(4)  ]]liat  is  tJie  position  of  the  loadized  abscess  ichich  we  have  decided 
to  be  present  ? 

The  outlines  of  this  position  are  at  once  determined  by  percussion 
and  palpation.  A  glance  at  fig.  143  will  show  the  chief  positions 
which  are  involved.     But  there  are   other  points  to  be  elucidated  in 


ACUTE   APPENDICITIS  335 

the  interests  of  correct  treatment,  and  these  demand  a  careful  exami- 
nation. In  the  first  place,  we  must  decide  whether  the  pus  is  intra- 
peritoneal, retroperitoneal  or  even  sub-fascial,  i.t\,  beneath  the  fascia  of 
the  iliacus  muscle.  If  the  abscess  definitely  projects  into  the  abdo- 
minal cavity,  it  is  intraperitoneal.  If  it  fills  the  pelvic  fossa  and  its 
shape  is  flat,  we  conclude  it  is  intraperitoneal ;  if  there  is  pronounced 
reflex  contraction  of  the  anterior  abdominal  wall  we  conclude  that  it  is 
retroperitoneal;  if  there  is  contraction  of  the  flexors  of  the  hip  joint,  and 
if  this  contraction  is  very  pronounced,  we  conclude  that  the  abscess  is 
under  the  iliacus  fascia.  If  the  resistance  is  more  in  the  lumbar  region, 
we  decide  for  an  intraperitoneal  position,  if  the  illness  started  with 
definite  signs  of  peritoneal  irritation  ;  but  if  not,  we  decide  for  retro- 
peritoneal position,  as  also  if  a  phlegmon  appears  in  the  lumbar  region 
after  a  few  days.  x-\bscesses  which  track  under  Poupart's  ligament 
are  always  sub-fascial.  In  doubtful  cases,  a  temperature  between 
102°  and  104°  F.,  and  rigors,  point  to  an  extraperitoneal  position. 

We  must  endeavour  to  determine  the  upper  and  lower  limits  of 
intraperitoneal  abscesses,  and  also  whether  they  are  in  contact  with 
the  anterior  abdominal  wall.  If  the  lumbar  region  is  painful  on 
pressure,  and  is  dull,  and  if  the  muscles  are  rigid,  it  signifies  that  the 
abscess  reaches  towards  the  kidneys,  generally  along  the  outer  side  of 
the  ascending  colon.  If  the  patient  complains  of  bladder  trouble, 
the  suppuration  extends  towards  the  true  pelvis.  If  rectal  symptoms 
are  also  present,  and  jelly-like  mucus  escapes  from  the  rectum,  the 
abscess  is  situated  in  Douglas's  pouch.  If  the  rigidity  of  the  anterior 
abdominal  wall  is  so  great  that  the  limits  of  the  abscess  cannot  be 
clearly  deterinined  by  palpation,  we  assume  that  it  is  directly  in  contact 
therewith.  If,  on  the  other  hand,  its  limits  are  very  easily  defined, 
there  is  probably  a  free  peritoneal  space  between  the  abscess  and  the 
anterior  abdominal  wall.  If  meteorism  is  present,  an  abscess  deeply 
situated  between  the  loops  of  the  small  intestine  (meso-coeliac)  may 
completely  elude  palpation.  Unless  we  have  watched  such  a  case 
from  the  beginning,  we  are  liable  to  diagnose  either  a  generalized 
peritonitis  or  an  ileus.  The  latter  mistake  is  all  the  more  pardonable, 
because  such  an  abscess  occasionally  causes  genuine  obstruction  by 
compi-essing  or  kinking  the  bowel. 

The  correct  determination  of  the  position  of  the  abscess  is 
important  in  order  to  decide  wheilicr  and  Jioiv  to  operate. 

If  we  see  a  patient  on  the  third  or  fourth  day  with  the  infiamed 
area  in  process  of  encapsulation  and  probably  already  subsiding,  we 
should  do  nothing  lest  we  disturb  the  natural  defences  of  the  body, 
or  rather  maintain  an  ''  armed  peace,"  because  the  process  may  burst 
forth  anew,  and  again  become  dangerous. 

If  the  general  and  local  symptoms  show  no  sign  of  subsiding  at 
the  end  of  the  first  week,  or  if,  indeed,  they  increase,  an  operation 


336      SURGICAL   DISEASES   OF   THE   ABDOMINAL   AND    PELVIC   VISCERA 

must  be  performed  without  any  further  delay,  not  so  much  for  tlie 
purpose  of  removing  the  appendix,  but  in  order  to  evacuate  the  pus 
and  thus  avoid  the  immediate  danger.  We  should  act  in  the  same 
way  if  a  primary  or  secondary  collection  of  pus  forms  anywhere 
during  the  second  or  even  the  third  week.  No  special  scheme  of 
operation  should  be  followed,  nor  should  any  particular  incision, 
recommended  by  one  surgeon  or  another,  be  adopted,  but  the  abscess 
should  be  opened  at  its  most  superficial  situation  and  with  as  little 
anatomical  damage  as  possible,  i.e.,  in  the  ileo-caecal  region,  lumbar 
region,  linea  alba,  or  finally  in  the  vagina  or  rectum.  Large  incisions 
are  not  only  unnecessary,  but  they  are  responsible  for  the  subsequent 
development  of  hernia  in  the  scars.  It  is  therefore  important  to  find, 
by  means  of  a  careful  local  diagnosis,  the  point  where  the  smallest 
incision  will  suffice.  If  the  pus  is  behind  the  peritoneum,  we  must 
approach  it  from  the  side.  If  it  is  deeply  situated,  in  the  meso-coeliac 
area,  separated  from  the  abdominal  wall  by  the  free  peritoneal  cavity, 
we  should  not  hurry  quite  so  much  with  its  incision  and,  if  necessary, 
must  carefully  protect  the  free  abdominal  cavity  during  the  operation. 
We  have  not  yet  said  anything  about  cxploratorv  puncture  in  the 
diagnosis  of  appendicitis.  Careful  observers,  and  those  who  have  had 
opportunities  of  witnessing  the  topographical  condition  during  opera- 
tions for  appendicitis,  will  not  feel  the  want  of  this  method.  As 
Roux  says,  "  It  is  not  always  free  from  risk,  is  often  useless  and  is 
always  unnecessary."  It  is  only  useful  in  subphrenic  or  pelvic 
abscesses  which  are  more  or  less  maccessihle  to  direct  examination, 
and  then  it  is  indispensable. 

We  have  hitherto  had  in  view  the  pure,  typical  attack.  But  if, 
either  through  our  own  fault  or  that  of  the  patient,  he  has  arrived  at 
a  stage  when  we  no  longer  have  full  control  over  the  disease,  we  have 
to  reckon  with  several  complications  which  will  make  demands  upon 
our  diagnostic  skill.  We  will  assume  that  the  initial  peritonitis,  as 
such,  has  been  overcome,  that  the  abdomen  has  become  temporarily 
softer,  the  respiration  quieter,  and  the  temperature  normal,  or 
approximately  so. 

One  group  of  complications  is  indicated  by  the  fact  that  the 
improvement  stops  short  at  a  certain  point,  and  that  the  temperature 
rises  again  and  takes  the  form  of  an  abscess  chart.  In  such  a  case  it 
is  very  probable  that  germs  diffused  throughout  the  abdominal  cavity 
are  developing  into  residual  abscesses,  the  favourite  positions  of  which 
are  indicated  in  fig.  143.  Experience  teaches  us  that  we  should  look 
for  them  in  Douglas's  pouch,  and  in  the  left  Hank  during  the  first  and 
second  week.  An  abscess  in  Douglas's  pouch  can  at  once  be  recog- 
nized by  rectal  examination.  If  we  have  neglected  to  search  for  it 
in  time,  our  attention  will  be  drawn  to  its  presence  by  a  discharge  of 
mucus  from  the  rectum,  by  tenesmus,  and  sometimes  even  by  failure  of 
-the  action  of  the  bowels.  Occasionally,  we  may  be  taken  by  surprise, 
by  the  spontaneous  rupture  of  the  abscess  into  the  rectum  or  vagina. 


ACUTE    APPENDICITIS  337 

An  abscess  in  the  left  fiaiik  is  easily  recognized  by  local  pain  on 
pressure,  by  muscular  rigidity  and  by  dulness.  We  should  also  think 
of  the  right  fianJi  if  the  case  has  not  been  operated  on,  or  if  the 
drainage  in  the  right  lumbar  region  is  inadequate. 

After  the  third  week  a  subphienic  abscess  is  the  most  likely  com- 
plication. It  rarely  comes  on  earlier,  and  is  usually  situated  on  the 
right  side.  If  nothing  abnormal  is  found  in  any  of  these  positions, 
and  the  abdomen  still  refuses  to  become  soft,  it  is  probable  that  small 
residual  abscesses  exist  between  the  coils  of  the  intestines.  It  is  best, 
as  a  rule,  to  allow  these  abscesses  to  become  spontaneously  absorbed, 
because  the  search  for  them  is  liable  to  do  more  harm  than  good. 

In  other  cases  the  complications  are  indicated  by  colic,  followed 
by  vomiting,  either  very  rapidly,  or  within  a  few  days.  The  tempera- 
ture remains  normal,  or  is  only  slightly  raised,  and  the  patients  appear 
to  be  quite  well  between  the  attacks  of  colic.  These  cases  certainly 
depend  upon  a  partial  or  complete  intestinal  obstnictioi,  due  to 
adhesions  and  kinking  of  a  coil  of  intestine.  These  complications 
usuallv  occur  in  the  fourth  to  the  sixth  week,  and  sometimes  earlier. 
Experience  shows  that  this  obstruction  has  a  greater  tendency  to 
disappear  spontaneously,  the  earlier  it  sets  in.  This  should  be  borne 
in  mind  as  a  therapeutic  indication. 

In  contrast  to  this  early  obstruction,  there  is  another  form  which 
may  come  on,  after  months  or  years,  and  which  is  due  to  narrow 
bands  of  connective  tissue.  Immediate  operation  is  required  in  this 
variety. 

If  we  unexpectedly  find  the  patient  very  feverish,  with  flushed 
cheeks  and  rapid  shallow  breathing,  and  with  a  dicrotic  pulse,  we 
should  at  once  suspect  a  respiratory  complication,  either  a  metastatic 
pneumonia  or  a  pleurisy.  In  the  latter  case,  we  may  be  quite  certain 
that  it  arises  from  a  concealed  focus  of  inflammation  in  the  lung,  or 
from  an  undetected  subphrenic  abscess— the  latter  especially  if  the 
pleurisy  is  on  the  right  side. 

Among  other  "  unforeseen "  complications  which  occasionally 
occur  in  appendicitis  may  be  included,  phlebitis,  parotitis,  and  other 
inflammatory  processes  which  can  easily  be  localized. 

Much  anxiety  is  often  caused,  both  to  the  medical  attendant  and 
the  patient,  by  the  long  persistence  of  sinuses  after  the  opening  of 
abscesses.  This  is  almost  always  due,  either  to  the  tubercular  nature 
of  the  disease,  or  to  a  faecal  concretion  which  has  escaped  from  the 
appendix  into  the  abdominal  cavity,  but  which  has  not  yet  been 
discharged  in  the  pus. 

The  foregoing  remarks  apply  to  the  cases  w^herein  it  is  possible  to 
diagnose  the  onset  of  appendicitis  with  certainty.  In  the  intermediate 
stage,   however,  the  diagnosis  is   much    more    difficult,  often   indeed 


338       SURGICAL    DISEASES    OF   THE    ABDOMINAL   AND    PELVIC    VISCERA 

impossible.  If  a  severe  case  of  appendicitis  happens  in  a  family,  the 
other  members  devote  considerable  attention  to  their  own  ileo- 
caecal  regions,  and  anxiously  consult  their  medical  adviser  as  to  the 
propriety  of  removing  the  appendix ;  they  complain  of  stabbing, 
burnmg  or  dragging  pains  in  that  vicinity,  and  feel  that  it  is  very 
sensitive  to  pressure.  With  the  very  best  of  intentions,  the  doctor 
can  detect  nothing  ;  his  diagnosis  must  be  that  of  a  hysterical  or 
imaginary  appendicitis,  and  he  sends  the  patient  home.  He  will 
generally  be  right,  but  not  always,  and  therefore  should  not  entirely 
lose  sight  of  the  patient. 

I  refused  to  operate,  under  these  circumstances,  on  a  voung  man 
upon  whose  sister  I  had  just  operated  ;  but  advised  him  to  report 
himself  if  he  really  got  a  genuine  attack  of  pain.  He  did  so  a  few 
weeks  later  on.  I  operated  at  once,  and  found  a  highly  inflamed 
appendix,  with  a  commencing  fibrinous  peri-appendicitis. 

What  criteria  can  guide  us  in  these  circumstances  ?  Historv  is  of 
the  first  importance.  If  the  patient  has  previously  had  an  "  inflam- 
mation of  the  bowels,"  which  can  be  designated  as  an  attack,  or  better 
still,  if  a  definite  antecedent  attack  has  been  reliably  observed  by  a 
doctor — not  a  mere  abdominal  pain  lasting  a  few  hours — the  patient 
is  correct,  and  we  must  accede  to  his  wish. 

But  if  the  ileo-c?ecal,  gastric  or  more  diffuse  pains  are  indefinite 
and  do  not  keep  the  patient  in  bed,  we  must  reserve  our  verdict.  It 
may  be  a  form  of  appendicitis  which  has  not  yet  developed  a  "  first 
attack,"  called  by  Ewald  "larval  appendicitis."  But  as  Gussenhauer 
has  remarked,  it  is  onlv  larval  in  the  sense  that  the  doctor  has  not 
been  able  to  diagnose  it.  But  in  this  connection,  the  remarks  made 
in  Chapter  XXXVI  should  be  recalled. 

The  physical  comUiion  will  often  fill  in  the  gap.  In  the  first  place 
we  must  endeavour  to  exclude  any  other  abdominal  disease,  especially 
in  women.  Then  we  should  palpate  the  normal  situation  of  the 
appendix.  Daily  experience  of  operations  during  the  free  interval 
teaches  us  that  this  is  not  at  the  point  where  the  outer  border  of  the 
rectus  meets  the  line  joining  the  anterior  superior  spine  with  the 
umbilicus,  which,  according  to  ]\IcBurney,  marks  the  orifice  of  the 
appendix.  It  is  the  ileo-ceecal  valve,  which  is  usually  situated  at  this 
spot.  The  position  of  the  appendix  is  more  simply  and  more 
certainly  ascertained  by  marking  the  spot  where  the  line  joining  the 
two  spines  cuts  the  outer  border  of  the  right  rectus  (Sonnenburg). 
If  nothing  abnormal  is  found  here,  or  in  an}^  of  the  other  situations 
usually  accredited  to  the  appendix,  we  still  remain  in  doubt  ;  and 
if  the  history  is  indecisive,  we  must  await  events.  If  the  history  is 
definite,  however,  the  negative  result  of  our  physical  examination 
is  of  no  significance.  If  there  is  a  complaint  of  moderate  pain  upon 
pressure,  but  no  change  can   be  detected  by  palpation,  we  must  rely 


COLITIS   AND    FUNCTIONAL    DISTURBANCES   OF   LARGE    INTESTINE    339 

upon  the  history,  because  a  certain  degree  of  sensitiveness  to  pressure 
may  exist  m  normal  circumstances.  But  if  this  pam  on  pressure 
is  very  pronounced,  and  much  greater  than  the  pain  caused  by 
pressure  on  the  left  side,  we  may  assume  that  some  chronic  in- 
flammation is  probable,  bearing  in  mind  the  possibility  of  chronic 
colitis  (see  next  chapter).  If,  iinallv,  we  discover  in  a  patient  with 
a  slightly  flexed  hip  a  sensitive  structure,  which  can  be  distinctly 
rolled  under  the  fingers,  we  must  regard  it  either  as  an  appendix  or 
an  adherent  mass  of  omentum,  bowel,  and  appendix,  and  should 
recommend  operation  to  the  patient. 

We  have  already  seen  that  it  is  quite  exceptional  to  be  able  to 
palpate  the  normal  appendix,  and  even  if  it  has  once  been  inflamed 
it  can  only  rarely  be  felt  during  the  free  interval. 


CHAPTER  XLVI. 


COLITIS,  SO-CALLED  CHRONIC  APPENDICITIS  AND 
FUNCTIONAL  DISTURBANCES  OF  THE  LARGE 
INTESTINE. 

Several  difterent  conditions  are  grouped  together  under  the  terms 
colitis,  chronic  appendicitis,  pseudo-appendicitis,  &c.  They  are  not 
all  really  examples  of  inflammatory  processes,  but  they  are  classified 
together  because  they  apparentlv  merge  into  one  another  by  means 
of  borderland  and  transitional  forms.  The  study  of  these  cases 
convinces  us  that  a  true  appreciation  of  them  can  only  be  obtained 
by  differentiating  those  due  to  organic  causes  from  those  originating 
in  functional  disturbance.     We  therefore  distinguish  : — 

^.—COLITIS  WITH  DEFINITE  ANATOMICAL  CHANGES. 

This  includes  all  the  cases  of  inflammation  which  are  recognizable 
by  definite  histological  changes,  and  which  usually  terminate  in 
ulceration  of  the  mucous  membrane.  As  these  cases  generally  come 
to  the  surgeon  in  the  stage  of  ulceration,  they  may  be  grouped  together 
under  the  term  of  colitis  ulcerosa. 

How  are  these  to  be  recognized  ?  Mainly  by  the  great  frequency 
of  the  diarrhoea,  by  the  admixture  with  mucus  and  occasionally  with 
blood,  or  at  least  with  traces  thereof,   and  also  by  tenesmus,   if  the 


340        SURGICAL    DISEASES    OF   THE    ABDOMINAL   AND    PELVIC    VISCERA 

disease  affects  the  lower  section  of  the  large  intestine.  The  physical 
signs  consist  of  the  rigid  contraction  of  some  intestinal  segments, 
or  their  inflammatory  infiltration.  The  symptoms  are  much  less 
definite  if  the  first  part  of  the  large  intestine  is  alone  involved,  because 
the  longer  course  of  the  intestinal  contents  may  enable  them  to  regain 
their  normal  state.  There  is  not  always  diarrhoea  in  these  cases,  and 
the  symptoms  are  usually  limited  to  vague  pains,  or  to  definite  attacks 
in  the  ileo-cascal  region,  which  are  usually  diagnosed  as  appendicitis. 

We  must  first  satisfy  ourselves  that  this  colitis  is  not  a  manifesta- 
tion of  a  more  grave  disease,  such  as  intestinal  cancer,  or  of  polypus 
of  the  large  intestine,  which  latter  is  very  rare.  It  is  a  serious  matter 
for  the  patient  if  he  is  treated  for  weeks  and  months  without  examina- 
tion of  the  large  intestine,  merely  for  mucous  and  bloody  evacuations, 
while  he  is  suft'ering  all  the  time  from  a  rectal  cancer,  which  could 
easily  be  felt.  It  must  also  be  very  annoying  to  all  taking  part  in  the 
case  if  it  is  allowed  to  go  on  until  the  surgeon  finds  the  growth  firmly 
fixed  in  the  true  pelvis.  Every  diagnosis  of  colitis  invariably  demands 
a  rectal  examination.  If  nothing  abnormal  is  found,  the  sigmoido- 
scope must  be  used,  and  the  whole  of  the  large  bowel  must  be  palpated 
for  a  tumour,  unless  it  is  quite  clear  from  the  history  and  the  onset 
of  the  disease  that  it  has  some  other  origin. 

Having  excluded,  as  far  as  possible,  a  new  growth,  and  naturally 
also  a  pelvic  abscess  irritating  the  bowel,  we  must  next  determine  the 
variety  of  tlie  colitis.  We  can  only  tell  for  certain  by  means  of  the 
sigmoidoscope  whether  the  case  is  chiefly  of  an  ulcerative  character. 
A  skiagram  may  very  probably  give  some  information  on  this  point, 
and  it  will  also  show  the  position  and  extent  of  the  disease.  As 
already  indicated  by  the  diarrhoea,  an  ulcerated  intestine  endeavours 
to  evacuate  its  contents  as  quickly  as  possible,  or,  to  put  it  scientifically, 
exhibits  increased  motility.  Stierlin  has  demonstrated  in  our  clinic 
that  this  peculiarity  is  shown  in  the  skiagrams  by  the  rapidity  with 
which  the  bismuth  meal  is  hurried  along  the  affected  portions  of  the 
bowel.  Indeed,  they  are  always  found  empty  when  a  series  of 
impressions  is  taken.  The  border  line  between  the  bowel  which  is 
pathologically  empty  and  that  which  is  normally  filled,  is  so  sharply 
defined  that  the  comparative  examination  of  several  impressions 
usually  gives  an  accurate  idea  of  the  extent  of  the  disease. 

We  must,  however,  make  one  reservation.  Portions  of  the  bowel, 
which  are  rigidly  infiltrated  by  tubercle  or  cancer,  show  the  same 
rapid  onward  movement  of  their  contents,  of  a  passive  character. 
We  can  tell,  by  means  of  a  bismuth  injection,  whether  the  condition  is 
one  of  excessive  motility,  or  one  of  conversion  of  the  bowel  into  a 
rigid  tube.  In  the  former  case  the  bowel  is  dilated  by  the  injection, 
but  not  in  the  latter  case. 

Having  recognized  the  ulcerative  character  and  the  extent  of  the 


COLITIS    AXD    FUNCTIOXAL    DISTURBANCES    OF    LARGE    INTESTINE     34I 

disease,  we  have  now  to  determine  its  nature.  Is  it  due  to  syphilis  or 
tubercle  f  Is  it  the  late  stage  of  an  mncvbic  enteritis,  a  dvscntery  caused 
by  tlie  Shiga-Kruse-Flexner-baciUus  f  Is  it  a  case  of  clirouic  ulcerative 
colitis  of  unknown  origin,  affecting  a  locaHzed  portion  of  the  large 
intestine  or  its  whole  extent,  of  a  type  to  which  attention  has  recently 
been  drawn  ? 

Let  us  take  syphilis  first.  This  is  usually  limited  to  the  lowest 
portion  of  the  large  intestine,  and  produces  the  well-known  clinical 
picture  of  rectal  syphilis,  which  we  shall  refer  to  later  on.  It  rarely 
extends  higher  up  into  the  bowel.  Our  diagnosis  will  be  supported 
by  the  history,  Wassermann's  test  and  by  the  presence  of  other  signs 
of  old  syphilis. 

Tubercle  is  much  more  important.  The  diagnosis  will  be 
suggested  by  a  tubercular  heredity  and  previous  history,  the  chronic 
start  of  the  malady,  and  by  other  existing  foci  of  tubercle.  A  positive 
diagnosis  can  only  be  made  by  a  histological,  or,  if  necessary,  a 
bacteriological  examination  of  a  piece  of  the  tissue  taken  from  an 
ulcer  with  the  aid  of  the  rectoscope.  The  discovery  of  tubercle 
bacilli  in  the  stools  is  of  value,  but  it  does  not  decide  the  diagnosis, 
because  the  patient  may  be  suffering  at  the  same  time  from  pulmonary 
tuberculosis. 

An  amoebic  or  bacillary  dysentery,  in  their  late  stages,  will  be 
suggested  if  the  patient  comes  from  a  district  in  which  these  diseases 
are  endemic,  chiefly  from  the  Tropics.  Physical  examination  does  not 
elucidate  matters  in  these  late  stages,  as  long  as  we  do  not  possess  an 
effective  serum  test. 

If  there  is  nothing  pointing  to  any  of  the  above-mentioned  forms, 
we  may  assume  that  the  case  is  one  of  chronic  ulcerative  colitis,  of 
unknown  origin. 

But  it  may  be  asked,  what  has  all  this  to  do  with  surgerv  ? 

As  far  as  diagnosis,  and  especially  differential  diagnosis,  is  con- 
cerned, the  position  is  clear.  But  experience  has,  however,  shown 
that  the  most  reliable,  and  often  the  onh%  remedy  for  ulcerative  colitis 
is  to  divert,  by  means  of  operation,  the  intestinal  contents  into  a 
Ccecal  opening,  in  order  to  put  the  large  intestine  at  rest.  Benefit 
sometimes  follows  the  partial  rest  given  by  a  simple  appendicostomy 
or  by  a  narrow  cascal  fistula.  In  tuberculosis  we  often  go  beyond  this 
and  completely  remove  the  whole  of  the  diseased  segment  of  the  large 
intestine  if  the  other  abdominal  organs  are  healthy. 

Whereas  amoebic  or  bacillary  colitis  is  extensive  in  its  area, 
tubercular  ulcers  usually  are  more  limited  in  their  distribution,  the 
favourite  sites  being  the  cascum,  ascending  colon  and  sometimes  also 
the  beginning  of  the  transverse  colon.  The  ulcers,  associated  with 
ulcerative  colitis  of   unknown    origin,   are   also    frequently   limited  to 


342       SURGICAL    DISEASES    OF    THE    ABDOMINAL    AXD    PELVIC    VISCERA 

definite  segments  of  the  large  intestine,  to  the  caecum  on  the  one  hand 
and  the  sigmoid  on  the  other — sometimes  referred  to  as  ulcerative 
typhlitis  and  sigmoiditis.  This  localization  is  explained  by  the  fact 
that  the  faeces  are  retained  longest  in  these  positions  and  therefore 
they  become  loci  ininoris  resistenticv.  The  sigmoid  is  also  particularly 
liable  to  localized  disease  in  women,  owing  to  its  unfortunate  proximitv 
to  the  internal  genital  organs  with  their  infirmities. 

As  the  disease  of  the  intestinal  mucous  membrane  penetrates  into 
the  deeper  layers,  reaction  appears  in  the  serous  membrane  in  the 
form  of  fibrin  deposit  or  as  a  localized  hyperemia — according  to  the 
severity  of  the  mfiammation.  If  the  disease  of  the  mucous  membrane 
persists  for  a  long  time,  hbrous  deposits  eventually  occur,  and  an 
extensive  peri-colitis  develops,  which  is  also  cdMed  pcri-fyphlitis  (inde- 
pendent of  the  appendix)  or  peri-siginoiditis — according  to  its  position. 
The  peri-colitis  rarely  proceeds  to  suppuration.  It  is,  however,  both 
superfluous  and  inappropriate,  to  invest  peri-colitis,  which  is  always 
secondary,  with  the  dignity  of  separate  disease. 

5.— FUXXTIOXAL  DERAXGEMEXTS  OF  THE   LARGE 
IXTESTIXE,  WITHOUT  TYPICAL  AXATOMICAL  CHAXGES. 

The  more  names  a  disease  possesses,  the  less  definite  is  our 
knowledge  of  it.  Muco-membranous  colitis,  with  which  we  shall 
mainly  deal  in  this  section,  has  received  at  least  a  dozen  different 
names  during  the  last  thirty  years.  This  disease  embraces  all  the 
functional  derangements  which  may  affect  the  large  intestine  :  motor 
derangements,  in  the  form  of  co/zs/zy^r/f/o//  alternating  with  duirrlitea ; 
sensory  dercingements,  in  the  form  of  regularly  recurring  colic  or 
severe  seizures  thereof  ;  secretory  derangements  in  the  form  of  persistent 
or  occasional  copious  discharge  of  mncns,  either  in  a  glairy  condi- 
tion, or  as  coagulated  masses  of  a  tape-like  or  tubular  shape.  Clinical 
experience  shows  that  this  symptom-complex  mav  come  on  after 
some  psychical  disturbance,  may  last  for  months  or  even  for  years, 
and  then  disappear  as  a  result  of  mental  excitement — without  anv 
typical  anatomical  change.  But  this  symptom-complex  may  also 
represent  the  reaction  of  the  large  intestine  to  various  pathological 
conditions,  both  within  and  without  itself,  ranging  from  cancerou>, 
tubercular  or  other  ulceration  to  displacements  of  the  large  intestine 
and  inflammatory  processes  in  its  vicinitv.  It  may  also  be  due  to 
toxic  causes,  such  as  alcohol,  tobacco  and  mercury,  and  also  to 
bacterial  poisons. 

The  latter  circumstance  explains  the  erroneous  conception  of 
muco-membranous  colitis,  as  the  result  of  an  intestinal  infection. 

The  main  surgical  interest  of  this  disease  concerns  its  diagnosis. 
The   practitioner  must    recognize   it    as    a    disease    in    itself,  which, 


COLITIS    AND    FUXCTIOXAL    DISTURBANCES    OF    LARGE    INTESTINE     343 

especially  in  women,  is  capable  of  mimicking  all  possible  painful 
affections  of  the  abdominal  cavity,  and  which  makes  neurasthenics 
fearfully  apprehensive  of  cancer,  but  he  must  also  appreciate  the 
important  fact  that  this  disease  may  be  a  concomitant  manifestation 
of  genuine  cancer.  It  also  has  surgical  interest  from  the  point  of 
view  of  treatment,  because  attempts  have  been,  and  are  still  bein<> 
made  to  cure  the  very  severe  forms  of  the  disease  bv  procedures, 
varying  from  a  simple  caecostomy  to  extensive  resections  of  the 
bowel,  as  no  prospect  of  recovery  is  offered  by  medical  treatment, 
including  baths,  diet,  electricity  or  psycho-therapy.  It  is  sometimes 
quite  impossible  to  restore  the  intestinal  reflex  actions  to  a  normal 
condition,  in  a  neuropathic  individual,  ni  whom  all  reflexes  are  out 
of  gear. 

The  prognosis  is  most  favourable  in  those  cases  wherein  we  have 
been  able  to  cure  some  causative  disease,  such  as  cholelithiasis, 
a  malady  of  the  female  genitalia,  or  appendicitis.  In  regard  to  this 
last,  however,  our  prognosis  must  be  guarded,  as  we  shall  see  later 
on.  The  connection  between  appendicitis  and  muco-membranous 
colitis  does  not  always  turn  out  as  we  expect,  and  the  colitis  mav 
continue  despite  the  removal  of  a  diseased  appendix. 

The  entire  large  intestine  does  not  invariably  exhibit  this  abnormal 
reaction,  nor  are  all  the  three  previously  mentioned  forms  of  functional 
disturbance  fully  pronounced.  As  a  rule,  only  the  motor,  and  to 
some  extent,  the  sensory  disturbances  are  in  evidence,  while  the 
secretory  derangements  are  either  absent  or  not  striking.  The  con- 
dition is  then  essentially  one  of  painful  constipation.  This  leads 
to  the  question  of  the  loccilizafioii  of  flic  fuiiciional  deraugcuienf,  which 
mav  be  solved  by  X-ray  examination. 

If  a  meal,  consisting  of  200  grm.  of  carbohydrate  porridge  and 
80  grm.  of  barium  sulphate,  is  given  to  a  normal  individual,  the  whole 
of  it  will  be  found  in  the  caecum,  ascending  colon  and  to  some 
extent  in  the  beginning  of  the  transverse  colon,  after  six  to  eicrht 
hours.  The  ascending  colon  is  empty,  or  nearly  so,  after  twelve  to 
eighteen  hours,  and  the  contents  are  seen  or  are  visible  in  the  lower 
section  of  the  large  intestine.  The  whole  intestinal  canal  is  emptv 
after  twenty-four  to  thirty  hours.  If  digestion  in  the  large  intestine 
is  slow,  the  delay  may  be  distributed  over  the  whole  oi  the  large 
intestine,  or  it  may  occur  exclusively  in  that  section  wherein  the 
faeces  remain  longest  in  order  to  become  inspissated,  namely  in  the 
first  portion  as  far  as  the  level  of  the  gall-bladder  (Stierlin's  asxending 
type  of  constipation).  The  delay  may  also  occur  in  the  last  section 
of  the  large  intestine  (sigmoido  and  proctogenic  constipation). 

In  our  experience  the  ascending  type  of  constipation  gives  rise  to 
most  subjective  symptoms.  This  is  due  to  the  fact  that  the  intestinal 
contents  in  this  position  are  still  semi-liquid  and  are  more  prone  to 
cause  fermentation  with  the  development  of  gases  than  the  more 
or  less  dry  faeces  retained  in  the  sigmoid,  or  lower  down. 


344      SURGICAL   DISEASES    OF   THE   ABDOMINAL   AND    PELVIC   VISCERA 

All  this  prepares  us  for  the  conception  of  a  clinical  picture,  which 
has  been  described  in  France  for  the  last  fifteen  years  under  the  terms 
of  typlilocolite  or  iyphlite  ptosiqiie.  It  has  only  generally  been  recog- 
nized in  Germany  quite  recently  as  caxiiiii  mobile  (Wilms),  typhliklasic, 
typhlatoiiie,  &c. 

In  the  year  1897,  shortly  after  the  appendicitis  rage  set  in, 
there  was  a  great  tendency  to  ascribe  all  ills  in  the  ileo-caecal  region  to 
the  appendix,  and  the  old  idea  of  stercoral  typhlitis  was  entirely 
discarded.  At  this  time,  however,  Dieulafoy,  who  was  himself  an 
advocate  for  early  operation  in  real  appendicitis,  pointed  out  that  there 
were  attacks  of  pain  in  the  ileo-caecal  region  which  had  nothing  to 
do  with  the  appendix,  but  which  signified  the  localization  of  the  muco- 
membranous  colitis  in  the  caecum.  Although  names  and  theories 
have  undergone  much  change  since  then,  or  rather  have  been  consider- 
ably multiplied,  no  real  advance  has  been  made  upon  the  position 
defined  by  Dieulafoy. 

The  established  facts,  as  far  as  they  possess  diagnostic  importance, 
may  be  summarized  as  follows  : — 

There  are  many  persons,  mainly  females,  who  complain  of  their 
caecal  region,  but  who  never  get  real  attacks  of  appendicitis,  lasting 
days  or  weeks,  with  the  development  of  resistance  or  peritoneal 
exudation.  The  so-called  "attack"  usually  resolves  itself  into  a 
severe  seizure  of  pain  about  the  caecum,  which  only  lasts  a  very  few 
hours  and  has  generally  disappeared  by  the  time  the  doctor  arrives. 
But  if  the  patient  can  be  examined  during  the  attack,  it  will  be  found 
that  tenderness  exists  in  the  ileo-caecal  region  on  pressure,  but  that 
there  is  no  muscular  rigidity.  Indeed,  a  structure  like  an  elastic 
cushion  may  be  felt,  and  sometimes  this  vanishes  under  the  hands  of 
the  examiner ;  but  if  it  can  be  carefully  palpated  it  will  be  recognized 
as  the  distended  caecum.  Exceptionally,  the  temperature  may  be 
somewhat  raised,  and  patients  with  active  reflexes  are  liable  to  vomit. 
Sometimes  the  attack  terminates  in  looseness  of  the  bowels,  at  other 
times  in  diarrhoea.  Then  the  tenderness  on  pressure  also  disappears  ; 
no  localized  pain  remains  over  the  appendix  for  a  few  days,  as  is  the 
case  even  after  a  mild  appendicitis.  On  the  other  hand,  we  do  find, 
as  Dieulafoy  has  pointed  out,  painful,  contracted  portions  of  the 
large  intestine,  indicating  a  state  of  abnormal  irritability  or  chronic 
colitis,  and,  occasionally,  the  onset  of  mucous  discharge  confirms 
the  diagnosis. 

The  caecum  can  often  be  felt  to  be  movable  and  capable  of  being 
displaced  hither  and  thither.  A  skiagraphic  examination  of  intestinal 
function  will  show  that  the  contents  are  unduly  delayed  in  the  caecum 
— i.e.,  constipation  of  the  ascending  type. 

Many  of   these   cases    have    been    submitted    to   operation,   some 


COLITIS    AND    FUNCTIONAL    DISTURBANCES    OF    LARGE    INTESTINE    345 

under  the  mistaken  diagnosis  of  appendicitis;  others  were  diagnosed 
correctly  and  were  operated  on,  because  the  disease  was  interfering 
with  the  nutrition  of  the  patients  and  their  ability  to  do  their  work. 
The  anatomical  conditions  found  consist  of  a  large  c?ecum  extend- 
ing low  down,  a  normal  appendix,  remains  of  inflammatory  adhesions 
on  the  caecum  itself,  and  the  so-called  peri-colonic  veil  (which  is 
merely  the  stretched  mesenteric  attachment  caused  by  the  tilting 
of  the  caecum)  on  the  ascending  colon,  reaching  as  far  as  the  hepatic 
flexure.  These  changes  do  not,  however,  explain  all  the  symptoms, 
even  if  we  include  the  kinking  of  the  small  intestine  in  front  of 
Bauhin's  valve,  as  recently  described  by  Lane.  At  least  every  tenth 
person  has  an  abnormally  movable  caecum,  and  very  frequently 
adhesions  and  kinks  produce  no  symptoms  at  all.  Delay  of  the 
faeces  in  the  caecum  also  occurs  without  symptoms.  We  must, 
therefore,  revert  to  our  original  view  that  functional  causes  play  the 
chief  role  in  all  these  troubles  of  the  large  intestine.  A  normally 
innervated  large  intestine  overcomes  all  possible  difficulties,  and  even 
resists  the  effects  of  abnormal  conditions  of  nutrition  and  life  gener- 
ally. But  if  the  innervation  of  the  bowel  departs  from  the  physio- 
logical standard,  it  reacts  towards  abnormalities  in  the  mode  of  life 
and  slight  mechanical  difficulties,  by  simple  constipation  or  by  more 
or  less  definite  symptoms  of  muco-membranous  colitis. 

We  are  now  in  a  position  to  state  what  we  mean  by  the  rather 
inappropriate  expression,  chronic  appendicitis.  Logically,  the  term 
should  only  be  applied  to  that  form  of  appendicitis  in  which  the 
appendix  does  not  recover  from  its  inflamed  condition.  This  is 
especially  the  case  with  tubercular  appendicitis,  but  this  condition 
requires  no  new  name.  It  also  occurs  in  very  many  ordinary  attacks 
of  appendicitis,  wherein  the  complete  subsidence  of  tlie  inflamma- 
tory symptoms  is  prevented  by  faecal  concretions,  stenoses,  adhesions, 
and  kinks.  In  some  cases  the  owner  of  the  appendix  is  unconscious 
of  this  chronic  irritation  ;  in  other  cases  he  suffers  frequent  but 
sHght  pains,  reflex  disturbances  of  the  intestinal  function,  and  even 
from  muco-membranous  colitis.  Other  patients  only  experience  an 
indefinite  discomfort  in  the  right  side  of  the  abdomen.  As  most 
appendices  which  have  suffered  from  several  attacks  remain  in  a 
state  of  chronic  irritability,  there  is  no  object  in  separating  them 
clinically  from  those  cases  in  which  this  irritation  becomes  more 
pronounced  than  usual.     This  constitutes  one  class. 

The  other  class  has  nothing  at  all  to  do  with  the  appendix.  It 
embraces  those  cases  which  were  formerly  justifiably  termed  ster- 
coral typhlitis,  and  consists  of  localized  ulcerative  colitis,  localized 
functional  disturbances  of  the  large  intestine  in  their  various  forms, 
such   as  '' typhlo-colite,"  caecal   distension,  &c.,  either  of  mechanical 


346       SURGICAL    DISEASES    OF    THE    ABDOMINAL   AND    PELVIC    VISCERA 

or  functional  origin.  It  is  obvious  that  these  cases  ought  not  to 
be  called  chronic  appendicitis. 

We  would  not  have  gone  into  this  matter  so  much  in  detail  were 
it  not  that  it  possesses  great  practical  importance. 

When  may  the  practitioner  be  satisfied  with  the  assumption  that 
the  case  is  one  of  mere  functiona!"  disturbance  of  the  Ccecum,  and 
therefore  abstain  from  operation  during  the  first  twenty  hours  ? 
He  is  justified  in  this  course  if  the  attacks  are  frequent  and  of  short 
duration  (only  a  few  hours),  if  there  is  mucous  discharge  and  a 
pronounced  neuropathic  history,  and  if  the  actual  attack  subsides 
within  a  few  hours.  This  affords  adequate  time  for  observation,  so 
as  not  to  miss  the  opportunity  of  early  operation  if  the  case  is  one 
of  genuine  appendicitis.  In  this  connection  it  must  be  emphasized 
tliat  pulse  and  temperature  are  in  no  way  decisive,  because  we  have 
seen  cases  of  appendicitis  with  pus  formation  wherein  the  pulse  has 
not  exceeded  100  per  minute  and  the  temperature  has  not  been 
above  gg'S-  A.  leucocyte  count  is  of  some  value,  because  a  definite 
leucocytosis  indicates  appendicitis,  but  if  the  leucocytes  are  normal 
in  amount  it  cannot  be  regarded  as  an  argument  against  the  disease. 
If  the  patient  has  not  recovered  at  the  end  of  the  first  twenty-four 
hours  it  is  our  duty  to  propose  operation.  It  is  to  be  hoped  that 
the  recently  acquired  knowledge  regarding  the  caecum  and  the 
ascending  colon  will  not  increase  the  mortality  from  appendicitis 
throu£ih   neglect  of  oneration. 


CHAPTER  XLVII. 

INTESTINAL  OBSTRUCTION. 

One  of  the  most  grateful  tasks  which  can  fall  to  the  lot  of  the 
surgeon  is  to  relieve  a  maladv  which  is  popularly  recognized  to  be 
attended  with  great  suft'ering.  Early  diagnosis  and  an  accurate 
appreciation  of  the  moment  to  interfere,  are,  however,  essential  for 
this  purpose.  Cases  of  intestinal  obstruction  exemplify  better  than 
any  other  condition  how  dangerous  it  is  to  wait  for  the  fully 
developed  clinical  picture  before  arriving  at  a  decision.  To  pursue 
this  course  is  to  sacrifice  the  life  of  the  patient  to  refinement  in 
diagnosis,  excellent  thougli  the  motive  be.  There  is  no  object  in 
being  able  to  proclaim  at  the  autopsy  that  we  had  correctly  diagnosed 


INTESTINAL    OBSTRUCTION  347 

the  situation  and  nature  of  the  obstruction.  Our  main  object  must 
be  to  recognize  when  surgical  rehef  should  be  afforded,  although 
we  may  not  always  know  the  precise  position  and  character  of  the 
obstruction.  This  is  no  encouragement,  however,  to  laxity  in 
diagnosis.  On  the  contrary,  careful  observation,  tlioroiigh  examina- 
tion, and  a  consideration  of  all  signs  are  indispensable,  but  this 
must  be  done  rapidlv,  and  we  must  decide  rapidly,  if  our  reflections 
are  to  be  of  any  use  to  the  patient. 

In  practice  it  is  necessary  to  distinguish  two  great  groups  of  intes- 
tinal obstructions  :  (1)  A  complete  form  which  comes  on  snddenly; 
and  (2)  a  form  which  comes  on  gradually  and  which  is  incomplete 
while  it  is  developing  into  chronic  obstruction.  We  will  deal  first  with 
the  latter,  in  which  the  process  can  be  followed  more  leisurely  in  all 
its  details. 


I.— STENOSIS    OF   GRADUAL    DEVELOPMENT. 

(Chronic  Intestinal  Obstruction.) 

A.— SYMPTOMS. 

Colic,  i.e.,  the  painful  contraction  of  a  portion  of  the  intestine, 
is  the  first  symptom  of  narrowing  in  its  lumen.  But  colic  is  of 
such  frequent  occurrence  that  it  does  not  signify  very  much  by  itself. 
But  if  pains  of  the  same  type  regularly  recur  in  the  same  area  of  the 
intestine  they  definitely  point  to  a  local  trouble  in  the  shape  of  a 
local  obstruction  of  the  intestine.  This,  however,  is  not  sufficient 
for  a  diagnosis.  Such  pains  may  be  present  in  colitis  of  any 
origin. 

In  order  to  confirm  such  a  condition  it  is  necessary  that  there 
should  be  abnormal  dilatation  and  visible  or  palpable  contractions  of 
the  bowel  above  the  site  of  obstruction.  The  dilatation  is  recognized 
by  the  repeated  occurrence  of  a  highly  tympanitic  or  metalHc  note, 
occasionally  by  the  metallic  sound  of  the  peristalsis  at  the  same  site, 
and  by  spontaneous  crepitant  noises.  Abnormal  contraction  is  recog- 
nized by  the  periodical  hardening  of  the  bowel,  which  is  very  different 
to  the  contraction  of  the  intestine  in  colitis.  In  the  latter  case,  the 
bowel,  which  contracts  when  it  is  empty  or  contains  a  little  faeces, 
feels  like  a  firm  band  ("  corde  colique"  of  the  French),  whereas  the 
liardened  intestine — either  the  large  or  small — above  an  obstruction 
gives  one  the  impression  of  an  elastic  tumour.  That  we  are  dealing 
with  rigid  intestine  is  quite  clear  from  the  tympanitic  note  on 
percussion,  and  from  the  periodical  onset  and  disappearance  of 
resistance.  If  we  are  fortunate  enough  to  detect  a  buzzing  sound  at 
this  spot  as  the  resistance  disappears,  there  can  be  no  further  doubt 
about  the  existence  of  a  constriction.  This  applies  not  only  when 
23 


348       SURGICAL    DISEASES    OF   THE    ABDOMINAL   AND    PELVIC    VISCERA 

one  coil  of  intestine  hardens  and  relaxes  with  a  heaving  movement, 
but  even  when  a  whole  segment  of  bowel  shares  in  this  process — 
when,  as  sometimes  happens,  as  many  as  four  parallel  tumid  coils  are 
present  (fig.  152).  It  is  often  necessary  to  wait  and  watch  for  some 
considerable  time  at  the  patient's  bedside  in  order  to  witness  these 
phenomena,  if  they  cannot  be  elicited  by  palpation  of  the  bowel.  As 
the  illness  progresses  and  the  com.pensatory  hypertrophy  of  the  intes- 
tinal muscle  is  no  longer  able  to  overcome  the  obstruction,  com- 
pensatory disturbance  occurs,  which  declares  itself  by  persistent 
abdominal  distension,  leading  to  complete  intestinal  paralysis.  But 
this  distension  is  by  no  means  a  sine  qua  iioii  for  the  diagnosis  of 
stenosis  of  the  bowel,  as  beginners  often  imagine.  We  have,  for 
instance,  seen  a  case  of  ileo-caecal  stenosis  which  was  too  narrow  to 
admit  a  cherry-stone,  and,  nevertheless,  the  abdomen  was  quite  flat, 
or  even  depressed. 


Fig.  152. — Rigid  contraction  of  bowel,  through  obstruction  of  small  intestine  by  a 

fibro-sarcoma. 

The  above-described  symptoms  are  most  pronounced  in  stenosis 
of  the  small  intestine.  The  hardening  in  the  targe  intestine  is  often 
very  indefinite,  which  accounts  for  so  many  late  diagnoses.  This 
hardening  can  very  frequently  still  be  detected  in  stenosis  of  the 
ascending  colon  or  hepatic  flexure,  but  then  it  also  involves  the  lowest 
coils  of  the  small  intestine  after  Bauhin's  valve  has  been  thrown  out 
of  action. 

One  sign,  which  we  meet  with  in  acute  complete  obstruction,  is 
almost  completely  absent  in  incomplete  cases,  i.e.,  vomiting.  It 
occurs  first  when  the  obstruction  becomes  temporarily  or  persistently 
complete,  and  the  higher  up  the  obstruction  is,  the  earlier  it  takes 
place. 

The  condition  of  the  stools  affords  important  information,  but 
not  quite  so  much  as  is  generally  supposed.  One  often  hears  the 
verdict — there  is  no  obstruction  because  the  patient  has  normal 
stools  ;  or,  on  the  other  hand,  that  there  is  obstruction  because  the 
faeces    are    in    little    masses,    looking   like    sheep's   faeces.     The    one 


IXTESTIXAL    OBSTRUCTION  349 

conclusion  is  as  erroneous  as  the  other.  The  stools  form  themselves 
slowly  in  the  large  intestine  from  the  transverse  colon  onwards.  If  the 
obstruction  is  in  its  upper  part,  where  the  faecal  contents  are  normally 
liquid,  there  is  nothing  to  prevent  the  normal  formation  of  faeces 
below  the  obstruction.  The  patient,  therefore,  continues  to  have 
regular  well-formed  stools— often  up  to  the  moment  when  complete 
obstruction  comes  on.  Even  if  the  stenosis  is  in  the  neighbour- 
hood of  the  splenic  flexure  the  f^ces  may  still  be  formed  normally. 
But  when  changes  in  the  stools  ensue  as  a  result  of  more  deeply 
situated  stenoses  of  the  large  intestine  they  take  the  form  neither  of 
sheep's  faeces  nor  of,  "  tape,"  but  of  alternate  complete  retention 
• — still  euphemistically  called  constipation — and  the  evacuation  of 
pulpy,  soft  faeces.  This  means  that  the  intestinal  contents  above 
the  stricture  are  not  solid,  "inspissated,"  but  are  pulpy  or  putty-like  ; 
the  narrower  the  stricture  the  more  liquid  they  are.  If  in  a  case  of 
obstinate  constipation  we  meet  with  freces  of  the  shape  of  balls,  even 
very  small  balls,  there  is  no  occasion  for  anxiety,  for  we  may  safely 
assume  that  this  is  due  to  mere  sluggishness  of  the  bowel,  which 
leads  to  abnormal  inspissation  of  the  intestinal  contents,  in  contrast 
to  what  occurs  in  stenosis. 

In  a  case  of  mine,  the  medical  attendant  justly  suspected  cancer, 
on  account  of  persistent  diarrhoea,  the  patient  being  an  old  man. 
The  tumour  was  not  palpable  from  the  abdomen,  but  I  discovered  it 
at  once  on  bi-manual  recto-abdominal  examination.  It  was  situated 
below  the  sigmoid. 

The  so-called  ''tape-like"  faeces  occur  when  they  are  of  clayey 
consistence,  and  have  squeezed  themselves  through  a  constriction 
near  the  anus,  within  reach  of  the  finger — but  never  higher  up. 
Tenesmus  is  always  present  in  these  cases  (see  "Difficulties  in  Defaeca- 
tion  ").  In  every  case  of  ^^constipation  "  we  must  ascertain  its  duration. 
If  it  has  existed  for  years  there  can  be  nothing  seriously  wrong  ;  but . 
if  it  has  only  been  present  for  a  few  months  in  a  person  who  had 
not  been  constipated  previousl}',  it  is  a  serious  symptom  and  requires 
careful  examination. 

A  man,  aged  50,  consulted  his  medical  attendant  because  of  recent 
constipation.  He  found  nothing  in  the  abdomen  and  prescribed 
fruit.  The  patient  continued  to  eat  fruit  with  the  greatest  diligence 
for  four  months,  and,  eventually,  came  with  cancer  of  the  rectum, 
situated  so  high  up  that  it  was  hardly  operable. 

The  conclusions  to  be  derived  from  stools  mixed  with  blood  are 
only  relative.  If  blood  is  present  in  a  case  already  suspected  of 
cancer,  the  suspicion  is  thereby  strengthened.  But  we  must  not 
forget,  that  any  ulcerative  colitis  may  be  accompanied  by  the  passage 
of  blood.  Blood  may  also  be  present_  in  muco-membranous  colitis. 
In  these  cases  the  haemorrhage  is  seldom  profuse,  but  the  masses  of 


350       SURGICAL    DISEASES    OF   THE    ABDOMINAL   AND    PELVIC   VISCERA 

mucus  contain  within  them  specks  of  blood  which  lead  to  a  correct 
diagnosis.  The  rectal  mucous  membrane  sometimes  bleeds  when 
there  are  neither  ulcers  nor  internal  piles,  the  only  change  being  one 
of  hyperaemia. 

An  infcruiixtnrc  wiiJi  pus  indicates  a  deep  ulcerative  process  in  the 
lower  part  of  the  large  intestine,  such  as  may  occur  with  a  large 
excavating  cancer  or  d^'Senteric  ulcers.  If  the  cancer  is  situated 
higher  up,  the  pus  is  so  intimately  mixed  with  the  stools  that  it  is  no 
longer  separately  recognizable.  Any  considerable  evacuation  of  pus 
per  rectum  signifies  that  an  abscess  has  broken  into  the  bowel. 

The  significance  of  intermixture  ivith  iniicus  is  not  very  great, 
because  this  occurs  whenever  the  large  intestine  is  irritated,  in 
idiopathic  colitis,  as  well  as  in  colitis  which  follows  tubercle  or 
cancer. 

We  must  be  verv  careful  in  drawing  any  diagnostic  conclusions 
from  the  effect  on  the  genera!  condition,  because  if  the  compensa- 
tion is  satisfactory,  nutrition  does  not  at  first  suffer.  If  the  attacks  of 
colic  are  frequent,  the  patient  instinctively  diminishes  the  amount  of 
his  food,  and  therefore  emaciates,  even  if  there  is  no  persistent  con- 
stipation. The  question  of  emaciation  is  not  decided  by  the  amount 
of  fat  which  the  patient  retains,  but  by  the  amount  which  he  has  lost. 
It  is  enough  to  pinch  up  a  fold  of  skin,  especially  over  the  abdomen 
or  thigh,  to  show  us  what  was  there  before.  If  the  relative  obstruc- 
tion has  persisted  for  some  time,  there  will  always  be  a  certain  amount 
of  cachexia. 

B.— THE    POSITION    OF   THE    STENOSIS. 

Palpation  very  often  settles  the  question  of  position.  We  may  be 
quite  clear  about  the  site  of  the  stenosis  if  w^e  feel  a  tumour  in  the 
region  of  the  large  intestine,  or  if  we  observe  above  it  the  previously 
described  symptoms  of  hardening  of  the  bowel,  metallic  note,  &c. 
But  it  is  quite  another  matter  if  we  can  feel  nothing  in  the  quiet 
stage,  and  if  the  hardening  of  the  bowel  and  the  colicky  pains  do  not 
enable  us  to  localize  the  trouble.  In  such  circumstances  we  must 
endeavour  to  decide  by  means  of  systematic  examination  and  logical 
deduction.  But  we  must  first  realize  what  will  be  stated  later  on 
when  discussing  the  localization  in  acute  cases,  that  the  symptoms  in 
chronic  obstruction  are  not  pronounced  from  the  start,  because  the 
obstruction  is  only  incomplete.  We  shall  subsequently  refer  to  the 
importance  of  the  skiagram  in  diagnosing  the  locality  of  the 
obstruction. 

One  important  peculiarity,  which  may  give  rise  to  error,  should 
also  be  mentioned.  Wherever  the  obstruction  may  be  in  the  large 
intestine,  e.g.,  in  the  sigmoid,    the  maximum  dilatation  of  the   bowel 


IXTESTIXAL    OBSTRUCTIOX 


JD- 


will  not  be  immediately  above  it,  but  will  always  be  in  the  caecum,  as 
long  as  Bauhin's  valve  is  in  working  order.  The  explanation,  which 
can  be  inferred  both  experimentally  and  mathematicallv,  is  due  to  the 
double  factor  that  in  the  ascending  colon  and  caecum  the  diameter  of 
the  bowel  is  greater,  but  the  thickness  of  its  wall  is  less  than  in  the 
lower  parts  of  the  large  intestine.  This  also  explains  why  the  most 
numerous  and  the  deepest  ulcers,  which  follow  the  dilatation,  are  to 
be  found  in  the  caecum  and  ascending  colon,  even  if  the  obstruction 
is  at  the  lower  part  of  the  sigmoid. 

!■!:  A  veritable  ulcerative  tvphlitis  or  peri-typhlitis  may  arise  in  this 
way,  and  lead  the  practitioner  to  look  for  the  obstruction  at  the  valve, 
where  it  is  not  situated.  But  the  onset  of  peri-caecal  inflammation 
in  the  course  of  the  illness  will  actually  make  the  expert  think  of  the 
possibility  of  a  deeper  origin.  If  acute  perforation  occurs  in  a  case 
of  intestinal  cancer,  we  must  accordingly  not  look  for  it  just  above 
the  obstruction,  but  in  the  beginning  of  the  large  intestine.  I  have 
seen  a  dilatation  ulcer  burst  in  this  position  in  an  old  woman,  in 
whom  a  peri-metritis  had  constricted  the  rectum. 


C— FORM    AND    CAUSE    OF   THE    STENOSIS. 

Giridiuil  obstruction  of  the  lumen  of  the  bowel  is  the  result  of 
concentric  narrowing,  through  disease  of  the  intestinal  wall,  or  of 
external  pressure. 

(i)  Concentric  uarvoiviiig  occurs  especially  in  cancer,  tubercle, 
syphilis  of  the  bowel,  which  is  much  rarer,  and  finally  in  non-specific 
cicatricial  stenosis. 

The  differential  diagnosis  between  cancer  and  tubercle  is  de- 
termined by  the  age  of  the  patient  and  by  the  localization  of  the 
stenosis.  Tubercle  may  occur  at  any  age,  bat  the  multiple  form  of 
intestinal  tubercle  which  so  often  causes  constriction  has  been 
especially  observed  in  young  people,  whereas  ileo-Ccecal  tuberculosis 
occurs  both  in  the  young  and  old.  Tubercular  stenosis  may  also 
occur  in  the  further  course  of  the  large  intestine,  but  not  often.  The 
behaviour  of  carcinoma  is  different.  Cancer  of  the  small  intestine 
certainly  occurs  among  young  people,  but  it  is  a  rare  condition. 
Most  intestinal  cancers  are  to  be  found  in  the  large  intestine  after  the 
age  of  30,  the  upper  portion  being  affected  at  the  earlier  age-period, 
and  the  sigmoid  usually  after  50. 

The  condition  found  on  palpation  also  has  its  significance.  If  a 
chronic  obstruction  in  the  small  intestine  is  distinctly  palpable,  it  is 
most  likely  to  be  carcinoma,  because  a  tubercular  stricture  very  easily 
escapes  the  palpating  finger.  But  both  carcinoma  and  tubercle  are 
equally  easily  palpable  over  the  ileo-caecal  valve.  The  latter  is  less 
sharplv  circumscribed  than  the  former. 

In  cases  of  tubercle,  intestinal  symptoms  will   already  have  been 


35 


2      SURGICAL   DISEASES    OF   THE    ABDOMINAL   AND    PELVIC   VISCERA 


present  for  two  or  more  years,  periods  of  aggravation  alternating 
witli  occasional  longer  periods  of  improvement.  In  cases  of  cancer, 
the  patient  will  previously  have  enjoyed  good  health,  but  from  the 
moment  symptoms  appear  they  continue  to  become  progressively 
worse.  There  may  be  remissions,  and  occasional  improvement  in 
the  general  condition,  but  of  very  short  duration,  and  despite  the 
brief  time  during  which  the  malady  has  existed,  the  emaciation  is 
very  striking.  Exceptionally,  cancerous  stenosis  may  drag  on  for 
years  before  a  definite  clinical  diagnosis  can  be  made.  If  X-rays 
are  not  decisive,  an  exploratory  laparotomy  is  preferable  to  indefinite 
waiting.  It  should  also  be  mentioned  that  in  cases  of  ileo-cyecal 
tuberculosis,  a  mixed  infection  often  causes  acute  attacks  of  peri- 
typhlitis, which  are  at  first  mistaken  for  ordinary  appendicitis. 
I  have  encountered  large  abscesses  with  stinking  pus  in  such  cases. 

The    same   may  happen    in    cancer,  but 
much  more  rarely  than  in  tubercle. 

Carcinomala  in  the  rest  of  the  large 
intestine  as  far  as  the  splenic  flexure,  are 
easily  felt,  especially  as  they  usually  give 
rise  to  definite  tumours,  early  in  their 
course.  The  splenic  flexure  itself  is  not 
easily  accessible  to  palpation,  and  it  is 
necessary  to  get  the  patient  gradually 
accustomed  to  the  deep  palpation  which 
is  required.  The  same  applies  to  the  he- 
patic flexure,  especially  in  men.  Cancer 
of  the  sigmoid  cannot  often  be  felt, 
because  this  part  of  the  bowel  so  fre- 
quently lies  in  the  true  pelvis,  and  because 
the  growth  is  usually  very  small.  The 
bowel  looks  as  if  it  has  been  tied  round 
th  a  piece  of  string  (fig.  153),  and  not  as  if  it  is  affected  by  a 
growth.  Bi-manual  examination,  under  an  ansesthetic,  per  rectum 
and  abdominally,  is  often  indispensable.  If  the  obstruction  is  not 
found  higher  up,  recto-sigmoidoscopy  must  not  be  neglected,  be- 
cause this  is  the  only  method  which  reveals  the  condition  of  the 
lowest  10  to  12  inches  of  the  large  intestine. 

Cancer  of  the  rectum,  even  if  situated  low  down,  may  cause  extreme 
narrowing  of  its  lumen  and  produce  symptoms  resembling  ileus. 
But  the  history  of  these  cases  shows  that  the  chief  complaint  refers 
to  tenesmus,  so  that  to  mistake  a  rectal  cancer  for  one  higher  up  is 
hardly  conceivable,  if  a  history  is  at  all  obtainable,  and  if  a  rectal 
examination  has  been  performed,  w'hich  ought  never  to  be  omitted 
in  any  case  of  obstruction. 

Pure  cicatricial  constrictions  are  much  rarer  than  the  cancerous 
or  tubercular  variety.     They  should  only  be  thought  of  when  the 


Fig.  153. — Cancer  of  the  sigmoid 
in  the  shape  of  a  constricting  ring. 


Wit 


INTESTINAL   OBSTRUCTION  353 

history  definitely  suggests  the  possibihty.  Although  strictures  pro- 
duced by  typhoid  and  dysenteric  ulcers  do  not  possess  the  importance 
previously  ascribed  to  them,  we  do  know  now  that  injuries  of  various 
kinds  may  lead  to  stenosis.  For  instance,  coiitnsion  of  the  bowel  may 
cause  an  infiltration  in  its  wall,  and  this  may  lead  to  a  temporary 
disturbance  m  its  lumen,  but  it  very  rarely  results  in  a  permanent  or 
in  an  increasing  stenosis.  The  fearing  ojf  of  a  piece  of  mesentery,  or 
what  amounts  to  the  same  thing,  thrombosis  of  the  mesenteric  vessels,  is 
a  much  more  serious  matter.  The  interference  with  the  circulation 
injures  the  mucous  membrane,  and  by  its  destruction,  leads  to  a 
cicatricial  stricture,  even  if  the  nutritive  conditions  are  adequate  for 
the  other  layers  of  the  intestine. 

A  circular  stenosis  more  often  follows  the  replacement  of  a 
strangnlated  hernia,  whether  performed  by  the  bloodless  or  open 
method.  We  will  discuss  this  incident  in  connection  with  stran- 
gulated hernia. 

For  the  sake  of  completeness  we  must  mention  syphilitic  strictures, 
which,  however,  are  always  situated  in  the  rectum  and  therefore 
cannot  be  confused  with  strictures  higher  up. 

Sarcomata  and  innocent  tumours  rarely  cause  obstruction  of 
gradual  onset,  but  they  may  cause  more  or  less  complete  ob- 
struction through  volvulus   or   intussusception. 

(2)  We  now  turn  to  chronic  ileus  caused  by  tumonrs  pressing  on 
tlie  bowel  from  tlie  ontsidc.  The  actual  obstruction  may  depend  upon 
one  of  three  conditions — (i)  on  direct  compression,  (2)  fixation  of 
the  bowel  by  adhesions,  (3)  infiltration  into  the  wall  of  the  bowel. 
The  first  condition  is  the  rarest.  As  long  as  the  bowel  remains 
movable  it  can  usually  find  some  position  in  which  its  function  can 
be  maintained.  Therefore  it  is  that  chronic  ileus  so  rarely  occurs  in 
the  most  extensive  mnocent  tumours  as  long  as  they  are  not  affected 
by  inflammatory  irritation.  Even  in  cases  where  there  is  not  much 
room  for  dilatation  of  the  bowel  away  from  the  tumour — as  in  a 
fibro-myoma  fixed  in  the  true  pelvis — the  tumour  and  intestine  do 
not  usually  interfere  with  one  another.  A  retroflexed  pregnant 
uterus  is  an  exception  to  this  rule,  because  of  its  unrestrained  growth- 
But  in  the  case  of  a  malignant  tumour  which  fixes  itself  to  the 
adjacent  bowel  and  prevents  its  dilatation,  chronic  obstruction  from 
the  pressure  is  very  likely  to  occur,  even  if  the  growth  has  a  com- 
paratively small  circumference.  This  occurs  in  carcinoma  of  the 
kidney  and  ovary,  in  large  cancers  of  the  litems,  and  in  sarcomata  in 
various  positions  of  the  abdomen. 

The  symptoms  of  chronic  obstruction  in  inflammatory  processes 
are  milder  and  always  more  transitory.  In  these  cases  the  bowel 
is   simultaneously  compressed,  fixed  and    infiltrated,    the    latter  con- 


354      SURGICAL    DISEASES    OF   THE    ABDOMINAL   AND    PELVIC    VISCERA 

dition  interfering  to  some  extent  with  its  normal  peristalsis.  This 
variety  of  obstruction  is  most  prevalent  in  connection  with  abscesses 
and  band  formation  after  perl-inetritis,  appendicitis,  peri-ueplirifis  and 
tubercular  peritonitis. 

Hitherto  we  have  been  assuming  that  chronic  obstruction  is, 
despite  brief  interruptions,  a  slowly  progressive  malady,  wherein  the 
leisurely  development  of  symptoms  leaves  adequate  time  for  examina- 
tion and  reflection,  but  wherein  the  symptoms  never  cease  completely. 
This  is  true  for  most  cases,  at  least  in  a  certain  stage,  but  not  for  all 
cases,  and  especially  not  for  the  beginning  of  the  disease.  Chronic 
ileus  maybe  intermittent,  although  the  cause  of  the  disease  continues 
unchanged  Periods  of  colicky  pain  and  bowel  hardening  may 
alternate  with  times  when  the  patient  feels  nothing  abnormal.  This 
depends  upon  the  compensatory  state  of  the  intestinal  musculature 
and  possibly  upon  destructive  changes  within  the  stricture. 

In  such  cases,  the  medical  attendant,  who  is  called  when  the 
patient  feels  ill,  makes  a  correct  diagnosis  and  advises  operation. 
But  as  he  improves  the  patient  declines  to  entertain  the  idea  of 
operation,  and  he  consults,  for  the  persisting  "  dyspepsia,"  a  more 
cheerful  physician,  who  treats  the  case  in  the  intermediate  stage  and 
perceives  nothing  seriously  wrong,  and  reassures  the  patient  in  good 
faith.  But  the  catastrophe  is  not  long  delayed  ;  the  patient  is  brouglit 
on  to  the  operating  table  in  extremis,  too  late  for  him  and  for  the 
reputation  of  surgery. 

The  less  significant  the  symptoms  are  during  a  quiet  interval,  the 
more  weight  must  be  attached  to  the  history.  If  the  unequivocal 
signs  of  a  stenosis  have  only  once  been  reliably  observed,  i.e.,  localized 
colic,  probably  vomiting,  circumscribed  hardening  of  the  bowel  and 
the  characteristic  auscultation  sounds,  the  case  must  be  considered 
serious,  even  if  all  symptoms  have  temporarily  disappeared. 

Chronic  obstruction  is  not  always  progressive.  If  it  is  caused 
by  a  moderate  amount  of  scar  tissue,  e.g.,  after  a  strangulated  hernia 
or  an  injury,  it  is  quite  possible  that  the  symptoms  may  gradually 
abate  and  finally  disappear  completely.  This  is  even  more  likely  to 
occur  in  cases  wherein  the  lumen  of  the  bowel  is  interfered  with  by 
inflammatory  processes.  These  cases  constitute  a  fair  proportion 
of  instances  of  intestinal  obstruction  which  recover  without  operation, 
in  addition  to  cases  of  volvulus  and  intussusception  to  be  discussed 
later  on. 

Much  has  been  expected  from  X-ray  examination  in  the  diagnosis 
of  intestinal  obstruction,  but  not  all  the  anticipations  have  been 
realized  hitherto.  The  basis  of  the  examination  is  a  bismuth  meal, 
just  as  in  the  case  of  the  functional  derangements  of  the  large  intestine, 
discussed  in  the  previous  chapter. 

Narrowing  of  the  small  intestine  is  usually  the  result  of  tubercular 


INTESTINAL    OBSTRUCTION 


355 


stenosis.  The  narrowing  is  recognized  by  the  stagnation  of  the 
bismuth  meal  in  front  of  the  stenosis.  The  smaH  intestme  should 
normally  be  quite  empty  four  to   six  hours  after  a  bismuth  meal  of 


Normal  large  intestine  six 
to  ten  hours  after  bismuth 
meal. 


Normal  large  intestine 
twenty  to  twenty-four  hours 
after  bismuth  meal. 


Large  intestine  after 
twenty-four  hours  in  a  case 
of  spastic  contraction  of 
tranverse  colon. 


Large  intestine  in  case  ot 
tubercle  of  caecum  and 
ascending  colon.  (Absence 
of  shadow  in  diseased  areas.) 


Stagnation  of  faeces  in  cae- 
cum and  ascending  colon  in 
a  case  of  cancer  ot  sigmoid. 


(/) 

Loss  of  shadow  in  cancer 
of  transverse  colon  (x).  Stag- 
nation of  fasces  in  caecum. 
(Taken  after  twenty-four 
hours.) 


Fig.  154. — Semi-diagrammatic  illustrations  of  skiagraphy  of  large  intestine. 


200  grm.  of  porridge,  at  least  if  this  is  not  soon  followed  by  another 
larger  ordinary  meal,  which  would  tend  to  delay  the  expulsion  of  the 
bismuth  meal  from  the  stomach. 


356      SURGICAL   DISEASES    OF   THE   ABDOMINAL   AND    PELVIC   VISCERA 

The  following  facts  must  be  taken  into  consideration  in  regard 
to  the  large  intestine  : — 

{a)  The  higher  the  position  of  the  stenosis,  and  therefore  the  more 
hquid  the  faeces  are,  the  narrower  must  be  the  stenosis  in  order  to 
render  it  visible  on  the  skiagram. 

{h)  If  the  stenosis  is  situated  very  low  down,  the  stagnation  does 
not  occur  just  in  front  of  it,  but  in  the  caecum,  as  we  have  just  seen. 
Constrictions  of  the  descending  colon  and  sigmoid  are  mainly  in- 
dicated by  an  abnormally  filled  caecum  and  ascending  colon,  this 
fulness  persisting  longer  than  usual.  The  same  picture  is  also  seen 
in  constipation  of  the  ascending  type.  We  should,  therefore,  not 
suspect  or  assume  the  presence  of  an  anatomical  narrowing  unless 
repeated  skiagrams  show  a  stagnation  of  intestinal  contents  lower 
down  in  the  large  intestine,  and  always  in  the  same  place.  Our 
suspicion  will  be  confirmed  if  the  faecal  masses  always  preserve 
the  same  shape  at  this  spot.  There  may  be  a  funnel-shaped  gap 
in  the  shadow,  indicating  a  narrow  track  in  the  bowel,  or  the  loss 
of  shadow  may  be  at  the  side.  Repeated  examinations  are  indis- 
pensable, because  such  pictures  may  be  the  result  of  pure  accident. 
In  doubtful  cases  this  test  may  be  controlled  by  iiijectiiig  80  to  100  grm. 
of  bismuth  carbonate,  or  double  this  amount  of  barium  sulphate, 
in  i-g-  or  even  2  pints  of  very  thin  mucilage  of  starch.  But  as  such 
a  mucilage  trickles  through  most  constrictions,  they  are  not  always 
clearly  demonstrated  by  this  method.  Attempts  have  therefore  been 
made  to  follow  the  injection  on  the  screen,  and  the  results  have 
been  better.  The  temporary  stagnation  of  the  material  injected  has 
rendered  it  possible  to  localize  the  stenosis  in  a  few  cases.     (Haenisch.) 

Skiagraphy  renders  great  assistance  in  the  diagnosis  of  intestinal 
disorder,  and  may  be  able  to  localize  the  disease  when  other  methods 
fail,  but  as  we  have  already  said  in  connection  with  the  stomach,  it 
ought  only  to  be  employed  for  purposes  of  diagnosis  in  conjunction 
with  other  clinical  aids. 

Hirschsprung's  disease  occupies  a  special  position  in  the  study 
of  intestinal  obstruction.  The  disease  occurs  in  children — mostly  in 
little  boys — and  is  characterized  by  slight  symptoms  of  obstruction 
combined  with  extreme  distension  of  the  large  intestine  by  faecal 
masses.  The  blocked  bowel  is  quite  easily  visible  through  the  skin 
of  the  emaciated  patient.  On  making  a  rectal  examination  masses  of 
clay-like  faeces  are  at  once  encountered,  not  only  filling  the  ampulla 
but  dilating  it  very  considerably.  The  cleaning  out  of  the  bowel  with 
the  finger,  spoons,  and  similar  means,  may  occupy  may  hours. 

Apart  from  the  exceptional  cases  wherein  the  large  bowel  is  un- 
usually long  and  convoluted,  or  wherein  the  valve  formation  is 
abnormal,  this  disease  is  not  due  to  anatomical  changes,  but  merely 


INTESTINAL    OBSTRUCTION 


357 


to  a  purely  functional  disorder  of  defaecation.  The  little  patients 
neglect  their  bowels  either  because  of  some  accidental  pain — fissure 
of  anus — or  because  of  some  reflex  disturbance,  which  would  be 
called  "sluggishness"  in  older  patients.  The  habit  of  constipation 
is  thus  formed,  if  this  may  justly  be  termed  a  habit.  Unless  the 
mother  notices  this  condition,  the  faeces  collect  first  in  the  rectum, 
then  fill  up  the  sigmoid  and  finally  extend  beyond.  After  a  certain 
stage  has  been  reached,  spontaneous  evacuation  is  impossible,  owing 
to  fiyper-distension  of  the  bowel  and  sometimes  also  to  some  second- 
ary valve  mechanism.  If  assistance  is  not  i-endered,  these  children 
finally  succumb  to  marasmus  or  symptoms  similar  to  obstruction. 
The  widely  dilated  coils  of  intestine  are  easily  recognizable  in  a 
skiagram,  with  or  without  a  bismutii  meal. 

II.— ACUTE  INTESTINAL  OBSTRUCTION. 
A.— SYMPTOMS. 

Acute  intestinal  obstruction  differs  from  the  chronic  form  in  the 
suddenness  of  its  onset  and  the  completeness  of  the  stoppage.  It 
manifests,  within  the  course  of  a  fevv  hours  or  of  a  day,  the  incidents 


Fig.    155.  —  Hirschsprung's  disease. 

which  take  weeks  or  months  to  develop  in  chronic  cases,  and  shows 
more  besides.  In  addition  to  the  essential  symptoms  of  intermittent 
colicky  pains  and  localized  hardening  of  the  bowel,  there  occurs  the 
important  and  regular  sign  of  vomiting,  which  in  chronic  cases  is  only 
met  with  during  an  acute  exacerbation.  The  general  condition  deterio- 
rates rapidly  owing  to  the  lack  of  fluid  intake  and  to  the  absorption  of 
toxins.  The  urine  diminishes  in  amount  and  contains  indican  ;  the 
pulse,  which  at  first  is  quiet  and  full,  soon   becomes  rapid  and  small  ; 


358       SURGICAL    DISEASES    OF    THE    ABDOMINAL   AND    PELVIC    VISCERA 

the  breathing,  which  at  first  is  only  hurried  during  the  actual  colic, 
becomes  rapid  and  shallow  as  meteorism  increases,  and  the  patient 
dies  in  a  few  days  of  hunger  and  thirst,  unless  peritonitis  has  ended 
the  scene  more  quickly. 

The  diagnosis  is  often  rendered  difficult,  because  the  symptoms  of 
obstruction  mav  be  masked  by  those  of  the  initial  shock,  which  mani- 
fests itself  bv  accelerated  pulse  and  collapse.  In  a  very  severe  case 
these  symptoms  merge  almost  uninterruptedly  into  the  paralytic  mani- 
festations of  the  terminal  stage,  so  that  the  pure  signs  of  intestinal 
obstruction  are  not  observed  at  all.  In  such  a  case  the  diagnosis  may 
rest  between  acute  perforative  peritonitis  and  obstruction. 

Perforation  of  a  gastric  or  diiodeiiai  nicer,  with  its  disastrous 
symptoms,  must  be  thought  of  in  this  connection,  as  also  any 
condition  which  causes  sudden  shock  and  reflex  intestinal  paralysis, 
e.g.,  pancreatic  Jicemorrliage  and  inflaniniation,  torsion  of  an  ovarian  or 
onierdal  tnnionr,  embolism  of  the  mesenteric  arteries,  tnhal  abortion,  or 
ruptured  tnbe,  and  even  tabetic  crises.  Repeated  percussion  and 
auscultation  afford  the  best  aid  to  diagnosis.  If  we  repeatedly  hear 
at  anv  one  place  a  metallic  note,  splashing  or  ringing  noises,  or, 
exceptionally,  a  stenotic  murmur,  and  if  the  abdomen  appears  to  be 
asymmetrical,  with  a  localized  area  of  the  intestine,  despite  its  tym- 
panitic note,  more  resistant  than  its  surroundings,  we  ought  especially 
to  think  of  ileus.  But,  on  the  other  hand,  the  prevalence  of  dead 
silence  from  the  beginning  in  an  equally  distended  bowel  most  pro- 
bably points  to  peritonitis. 

B.— THE  POSITION  OF  THE  OBSTRUCTION. 

The  diagnosis  of  the  seat  of  obstruction  is  comparatively  easy 
when  it  is  either  high  or  low  ;  but  difficult  or  impossible  when  it  is 
in  the  mid-portions  of  the  intestine.  The  most  important  indications 
are  given  in  the  accompanying  table,  and  it  is  only  necessary  to  add  a 
few  general  observations. 

The  peristaltic  movements  in  the  small  intestine  are  much  more 
active  than  in  the  large  intestine.  But  no  conclusion  can  be  drawn 
from  the  degree  of  meteorism,  because  it  may  be  just  as  pronounced 
when  the  obstruction  is  low  down  in  the  small  intestine,  as  when  situated 
in  the  large  bowel.  "Meteorism  in  the  flanks"  (''cadre  cohque  "), 
ostensibly  a  sign  of  obstruction  in  the  large  intestine,  is  more  of  a 
theoretical  condition,  because  only  the  upper  and  middle  portions  of 
the  bowel  distend  to  any  great  extent — from  the  cjecum  to  the  trans- 
verse colon — so  that  the  frame  is  only  half  formed.  If  the  distension 
proceeds  further  onwards,  and  the  sigmoid  is  well  developed,  it  will 
involve  the  mid-portion  of  the  lower  abdomen,  but  will  not  form  a 


IXTESTIXAL    OBSTRUCTIOX 


359 


frame.  But  we  may  consider  it  established  that  a  high  tympanitic 
note  in  the  right  hmibar  region  points  with  great  probabiUty  to 
obstructioii  of  the  hir""e  boweL 


(a)  Obsiriiction  at  cardia. — Abdomen  flat,  regurgitation  of  food  by  cupfuls,  mixed  with  blood  and  mucus, 
often  alternating  with  vomiting.     Cancer,  rarely  cardio-spasm. 

{b)  Pyloric  obstruction. — Epigastrium  distended,  rest  of  abdomen  flat.  Vomiting,  by  the  dishful,  of  food 
taken  days  before,  mixed  with  gastric  juice  and  often  with  mucus,  blood  and  coffee  grounds.  No  bile.  Stenosis 
after  ulcer.     Cancer. 

(c)  Ditodeno-jejiinal  obstruc- 
tion.— Abdomen  as  in  c.  Splash- 
ing sounds  to  the  right  of  umbili- 
cus (lower  part  of  duodenum). 
Biliary  vomiting,  not  faecal. 
Arterio-mesenteric  intestinal  ob- 
struction, Treitz's  hernia,  tuber- 
cular band. 

{d)  Obstruction  at  upper  part 
of  small  intestine. — Meteorism,  if 
present,  moderate,  central  or 
diffuse.  Vomiting  biliar}-,  rather 
faecal,  powerful  peristalsis.  Bands, 
volvulus,  tubercle,  tumours,  intus- 
susception, internal  hernia. 

(e)  Obstructioii  at  loiver  part  0/ 
small  intestine.  Meteorism,  if 
present,  general.  Faecal  vomit- 
ing, powerful  peristalsis  (Causes 
as  in  d.) 

(y)  Obstmction  at  ileo-ccecal 
valve.  —  -As  in  e,  but  condition 
usually  palpable  in  right  pelvic 
cavity.  Intussusception,  volvulus, 
cancer,  tubercle. 

(g)  Obstruction  of  large  intes- 
tine at  hepatic  flexure.  Meteor- 
ism if  present,  general.  Caecum 
and  ascending  colon  distended. 
Active  peristalsis  occasionally. 
Faecal  vomiting.  Possible  to  in- 
ject li  to  2  litres  of  fluid  into  rec- 
tum. If  obstruction  incomplete, 
stools  are  formed.  Condition 
generally  palpable.  Cancer,  tu- 
bercle very  rarely. 

(A)  Obstruction  of  large  intes- 
tine at  splenic Jlexure. — Meteor- 
ism as  above,  but  transverse  colon 
also  somewhat  distended.  Injec- 
tions of  I  to  ij  litres  possible.  If 
obstruction  incomplete,  stools 
generally  forme'l.  Palpation  more 
often  negative  than  in  g.  Cancer, 
tubercle  very  rarely,  or  syphilis. 

(?)  Obstruction  at  sigmoid. — 
Meteorism  as  above,  main  disten- 
sion of  colon  at  caecum.  Slight 
peristalsis.  Injection  of  \  to  \  litre 
possible,  seldom  more.  If  obstruc- 
tion incomplete,  diarrhoea  alter- 
nates with  constipation.  Palpa- 
tion often  negative  owing  to  sirall- 
ness  of  growth,  but  sigmoidoscopy 
and  bi-manual  e.xamination  under 
chloroform  advisable.  Volvulus, 
cancer. 

(li)  Obstruction  in  upper  pari 
of  rectum. — Meteorism  as  above. 
Constipation  alternating  with 
diarrhoea,  or  always  thin  evacua- 
tions. Exceptionally  ribbon- 
shaped.  Tenesmus  occasionally.  Cause  detected  by  rectal  or  combined  examination, 
tumours  and  inflammation  within  true  pelvis. 

(/)  Ob'ttriiction  in  ampulla.— Tenesmus,  fluid  or  ribbon-shaped  stools.  Causes  :  Cancer,  syphilis.  Can  be 
felt  and  sometimes  seen. 


Fig.    156. — Diagram  of  the  typical  positions  of  intestinal 
obstruction. 


Cancer,   syphilis, 


Obstruction  high  up  leads  to  many  mistakes  in  diagnosis,  because 
flatus  and  stools  still  pass  and  the  abdomen  remains  flat,  even  if  the 
obstruction    is  long    persistent.     These    cases  often  suggest  cerebral, 


360      SURGICAL   DISEASES   OF   THE   ABDOMINAL   AND    PELVIC   VISCERA 

urasmic  or  even  hysterical  vomiting,  gastric  crises  or  the  onset  of 
peritonitis.  The  last,  however,  can  be  excluded  by  the  absence  of  any 
local  irritative  symptoms,  uraemia  by  the  condition  of  the  urine, 
cerebral  or  tabetic  vomiting  by  the  absence  of  any  other  cerebral  or 
spinal  cord  symptom.  The  obstinacy  of  the  vomiting,  the  rapid 
decrease  of  urine  and  the  cessation  of  the  passage  of  stools  and  flatus 
within  a  few  days  will  finally  convince  those  wiio  cannot  conceive  of 
intestinal  obstruction  without  a  drum-like  abdomen. 

We  cannot  expect  much  elucidation  from  X-rays  in  cases  of  com- 
plete intestinal  obstruction.  There  is  no  time  for  an  examination  of 
the  intestinal  movements,  because  immediate  operation  is,  as  a  rule, 
necessary.  It  is  quite  conceivable,  however,  that  X-rays  may  be  use- 
ful in  subacute  forms,  to  localize  the  obstruction  accurately,  when  it 
is  situated  high  up.  Similarly  in  cases  of  obstruction  low  down,  in 
the  large  intestine,  a  skiagram  may  be  valuable  after  a  bismuth  injection, 
more  especially  as  this  delays  the  operation  less  than  an  examination 
of  the  intestinal  movements.  Besides  this,  a  bismuth  meal  is  liable  to 
be  vomited,  and  the  site  of  the  stagnation  of  the  test  material  is  not 
the  position  of  the  obstruction.  But  a  skiagram  taken  after  an  injection 
has  not  only  a  theoretical  interest,  in  complete  obstruction  of  the 
large  intestine — the  time  is  too  precious  for  theoretical  examinations 
in  such  cases — but  possesses  the  great  practical  value  of  indicating  the 
correct  position  for  operative  interference. 

C— THE  GENERAL  VARIETIES  OF  ACUTE  OBSTRUCTION. 

Before  discussing  the  detailed  causes  of  acute  obstruction,  we  will 
glance  at  the  different  forms  in  which  it  may  appear.  This  considera- 
tion will  often  facilitate  accurate  diagnosis.  The  following  are  the 
main  varieties  : — 

(i)  Obstruction  passing  from  ail  I iiconipleie  Chronic  into  a  Teinporarily 
Complete — apparently  Acute,  Stage. — Cancerous  and  tubercular  disease 
constitute  the  chief  examples  of  this  group.  If  an  elderly  patient  who 
has  been  suffering  for  several  months  from  colic  and  increasing  dis- 
tension, has  passed  neither  stools  nor  flatus  for  two  days,  but  vomits 
bowls  full  of  brown  foetid  material,  it  is  highly  probable  that  he  has 
a  constricting  carcinoma  of  the  colon,  particularly  of  the  sigmoid.  If 
a  younger  man  with  tubercular  antecedents  and  a  history  of  months' 
or  years'  suffering  from  colic,  shows  signs  of  complete  obstruction, 
he  probably  has  a  tubercular  stricture  in  the  small  intestine  or  at 
Bauhin's  valve.  Many  cases  of  obstruction  during  the  course  of 
tubercle  or  cancer  of  the  peritoneum  should  be  included  in  this  group. 
In  both,  the  apparently  sudden  onset  of  complete  obstruction  will 
always  have  been  preceded  by  some  abdominal  discomfort,  especially 


INTESTINAL   OBSTRUCTION  361 

colic  and  loss  of  appetite,  which  shows  that  the  event  has  long  been 
in  preparation. 

(2)  Intcfinittent  Obstruction.- — This  term  applies  to  all  cases  wherein 
sudden  attacks  of  transitory  obstruction  alternate  with  intervals  of 
complete  freedom  of  a  variable  duration,  sometimes  even  of  years. 
There  is  no  permanent  narrowing  in  these  cases,  but  a  temporary 
obstruction  of  the  lumen  of  the  bow^el  repeatedly  occurs,  caused  by 
some  existing  abnormality,  which  becomes  latent  at  intervals,  or  by 
some  anatomical  change.  This  variety  is  mostly  exemplified  in  torsion 
of  the  sigmoid,  or  more  rarely  by  an  abnormally  movable  ileo-cascal 
segment  of  the  bowel,  or,  still  more  rarely,  of  the  small  intestine. 
Obstruction  by  omental  or  cicatricial  bands,  by  abnormalities  con- 
nected with  Meckel's  diverticulum,  strangulation  of  internal  hernia, 
kinking  produced  by  tubercular  adhesions,  as  well  as  arterio- 
mesenteric intestinal  obstruction,  may  belong  to  the  same  group. 

(3)  Sudden  and  nnanticipated  Onset  of  Acute  Obstruction. — This 
group  includes  the  rare  cases  of  sudden  obstruction  by  cancer  in 
apparently  healthy  individuals  without  any  pathological  antecedents. 
But  the  more  carefully  the  history  is  taken,  the  more  frequently 
some  indication  of  previous  disease  will  be  found,  if  only  some 
dyspepsia,  slight  pain,  irregularity  of  the  bowels,  or  unexplained 
wasting.  Obstruction  may  also  occur  suddenly  in  tubercle,  before 
any  diagnosis  of  intestinal  disease  has  been  made. 

All  the  enumerated  causes  of  intermittent  obstruction  come  into 
consideration  again  if  a  first  attack  is  under  observation.  Finally, 
there  are  cases  in  which,  as  a  rule,  one  attack  only  occurs,  e.g., 
intestinal  obstruction  from  gall-stones. 

D.— CAUSES    OF   ACUTE    INTESTINAL  ;OBSTRUCTION. 

We  now  propose  to  consider  whether  any  given  case  can  be 
referred  to  one  of  the  classical  forms  on  the  evidence  of  history 
and  physical  symptoms,  and  for  this  purpose  we  will  briefly  discuss 
the  most  important  of  these  forms,  begin nmg  with  those  to  wdiich 
the  history  provides  the  clearest  clues. 

(1)   Obstruction  due  to  Bands  and   Kinks. 

If  the  patient  has  had  an  abdominal  operation,  however  long  ago, 
we  shall  rarely  err  if  we  diagnose  obstruction  by  a  band.  Bands, 
which  result  from  operative  procedures  are  more  dangerous,  because 
they  are  usually  more  circumscribed  than  those  which  arise  spon- 
taneously after  inflammation.  Nevertheless,  the  latter  may  also 
produce  obstruction  by  bands,  6'.^.,  after  appendicitis,  cholecystitis, 
inflammation  of  the  female  genital  organs,  and  tubercular  peritonitis. 


362       SURGICAL   DISEASES    OF   THE    ABDOMINAL    AXD    PELVIC    VISCERA 

The  last  may  produce  adherent  omental  bands  in  the  true  pelvis. 
The  adhesions,  which  occur  after  ulceration  of  the  large  intestine, 
pericolic  cords  and  bands,  are  flatter,  and  therefore  are  more  liable 
to  give  rise  to  chronic  obstruction. 

If  signs  of  obstruction  in  the  upper  part  of  the  small  intestine 
occur  in  an  emaciated  individual,  the  subject  of  lateral  curvature  or 
Pott's  disease,  we  should  think  of  aiicrio-uiesenteric  intestinal  ohstriic- 
tioii,  i.e.,  kinking  of  the  small  intestine  at  the  duodenal  boundary 
by  the  root  of  the  mesentery.  A  duodenum  with  a  very  low-lying 
situation  is  necessary,  or  at  any  rate  is  a  favourable  condition  for 
the  causation  of  this  form  of  intestinal  obstruction.  The  knee-elbow 
position  removes  the  obstruction  and  confirms  the  diagnosis. 

The  classical  picture  of  arterio-mesenteric  intestinal  obstruction 
was  seen  in  a  girl,  aged  13,  the  subject  of  disease  of  the  cervical  spine 
and  compensatory  lordosis  in  the  lumbar  region.  The  stomach  and 
the  duodenum,  which,  as  the  operation  showed,  reached  considerabh^ 
to  the  right,  were  greatly  distended,  and  gave  evidence  of  splashing 
on  auscultation.  The  stomach  was  tympanitic  and  the  duodenum 
yielded  a  metallic  note.  The  cervical  disease  prev^ented  the  use  of 
the  knee-elbow  position  for  the  purpose  of  treatment,  and  the  fact 
of  tuberculosis  did  not,  of  course,  exclude  obstruction  by  a  band. 
Laparotomy  was,  therefore,  performed,  and  I  found  the  whole  of  the 
small  intestine  deeply  in  the  true  pelvis.  The  kink  was  situated  at 
the  junction  of  the  duodenum  with  the  jejunum.  The  latter  became 
.^lled  with  gas  as  soon  as  it  w-as  lifted  up. 

It  is  an  open  question  whether  one  should  include  here  the 
duodenal  obstruction  which  has  been  observed  after  laparotomy, 
especially  in  the  upper  portion  of  the  abdomen.  This  condition 
depends  upon  atony  of  the  gastric  musculature,  which  sometimes 
occurs  after  operations  on  the  abdominal  cavity,  and  is  analogous 
to  atony  of  the  rectum.  It  is  a  condition  which  certainly  occurs 
in  the  slight  infections  which  are  overcome  by  the  peritoneum  in 
a  few  days.  In  other  cases  the  peritoneum  possesses  an  idiosyncrasy 
towards  blood.  The  greatest  degree  of  rectal  atony  which  I  have  seen 
occurred  in  a  case  of  post-operative  haemorrhage,  which  was  bacterio- 
logically  sterile. 

(2)    Obstruction  by  Gall-stones. 

If  pain  on  pressure  over  the  gall-bladder  occurs  siniultaneonsly 
with  symptoms  of  acute  intestinal  obstruction,  the  case  is  probably 
one  of  acute  cholecystitis.  This  disease  frequently  produces  tem- 
porary signs  of  obstruction,  either  as  a  reflex  process  or  by  extension 
of  the  inflammation  to  the  transverse  colon  or  small  intestine. 

If  an  attack  of  gall-stones  Jias  occiiryed  previously  the  obstruction 
is  most  likely  to  be  due  to  a  gall-stone  rather  than  to  the  so-called 
"  bride-pericolique."  The  entrance,  even  of  a  large  gall-stone  into 
the  small   intestine,   usually   takes  place  bv  a  process  of  suppuration 


INTESTINAL    OBSTRUCTION  363 

without  any  striking  symptoms,  and  the  last  attack  of  gall-stones 
observed  by  the  patient  may  have  occurred  long  previously.  Some 
support  for  the  diagnosis  of  "  gall-stone  obstruction  "  is  afforded  by 
feeling  a  firm  and  somewliat  tender  swelling  in  Douglas's  pouch  on 
vaginal  or  rectal  examination.  Most  of  these  gall-stones  remain 
tixed  in  the  lower  portion  of  the  small  intestine,  and  the  coil  con- 
taining the  stone  is  dragged  down  into  the  cavity  of  the  true  pelvis. 

It  might  be  thought  that  gall-stone  obstruction  ought  to  be 
included  in  the  chronic  variety,  owing  to  the  length  of  time  the 
stone  remains  within  the  bowel.  This  is  true  for  some  cases,  wherein 
the  symptoms  are  very  protracted  and  remittent,  and  the  stone 
eventually  departs  spontaneously.  But  in  most  cases  the  symptoms 
come  on  very  acutely,  and  we  often  find  that  signs  of  peritonitis  super- 
vene at  the  same  time,  or  at  any  rate  very  soon  afterwards.  If  the 
stone  is  in  a  healthy  coil  of  intestine,  it  will  allow  flatus  to  pass  by  it. 
But  if  it  remains  for  any  length  of  time,  the  intestinal  wall  becomes 
irritated  and  draws  itself  lightly  over  the  stone,  which  then  allows 
nothing  to  pass  by  it.  At  the  same  time  a  pressure  ulcer  develops,  so 
that  the  intestinal  wall  becomes  inflamed  and  infiltrated,  and  instead 
of  grasping  it  by  active  contraction,  becomes  stiff  by  infiltration,  and 
embraces  the  stone  tightly  but  passively.  At  this  moment  the  "  attack 
of  gall-stone  obstruction  "  often  begins.  The  inflammation  rapidly 
involves  the  serous  membrane,  so  that  local  peritonitis  occurs  early. 
If  we  make  the  diagnosis  of  gall-stone  obstruction  in  such  a  case  on 
the  evidence  of  the  clinical  history,  we  must  not  hesitate  to  operate 
iininediately,  on  the  assumption  that  most  gall-stones  pass  through  the 
bowel  by  themselves.  The  actual  symptoms,  indeed,  show  that  the 
stone,  in  such  a  case,  will  not  do  so. 

The  following  is  an  illustrative  case  : — 

A  man,  aged  about  50,  who  had  suffered  from  a  severe  attack  of 
gall-stones  one  year  previous!}^,  was  suddenly  seized  at  night,  without 
any  warning,  with  abdominal  pain  and  vomiting.  Twelve  hours  later, 
the  pulse  was  already  rapid,  the  abdomen  tender  and  slightly  distended, 
and  contained  some  free  fluid.  The  vomiting  continued.  The 
diagnosis  wavered  between  obstruction  by  a  band,  or  by  a  gall-stone, 
combined  with  severe  peritoneal  irritation  and  slight  effusion.  Opera- 
tion was  done  at  once,  and  a  gall-stone  was  found  in  the  lower  portion 
of  the  small  intestine,  in  firm  contact  with  the  inflamed  and  infiltrated 
bowel.  A  pressure  ulcer  had  already  perforated,  and  the  abdomen 
contained  sero-purulent  fluid.  The  operation,  however,  was  unable 
to  restrain  the  advance  of  the  peritonitis. 

(3)  Intussusception. 

Exceptionally,  a  positive  indication  is  supplied  by  the  age  of  the 
patient.  This  is  true  of  intussusception  in  so  far  as  it  occurs  in 
infants,  who  very  rarely  suffer  from  anv  other  form  of  obstruction. 
The  symptoms  vary  with  the  degree  of  disturbance  of  the  circulation 
in  the  invaginated  portion,  and  they  range  from  the  very  severest  type, 

24 


364      SURGICAL    DISEASES    OF   THE    ABDOMINAL   AND    PELVIC    VISCERA 

with  rapid  death  from  peritonitis,  to  chronic  intussusception  of  many 
months'  duration.  The  beginning  of  the  disease  is  usually  marked 
by  the  passage  of  blood-stained,  fruit-juice-like  fluid  with  the  stools,, 
and  the  intussusception  can,  as  a  rule,  be  felt,  on  careful  examination, 
as  a  sausage-shaped  swelling,  close  to  the  spinal  column.  The  intus- 
susception rarely  reaches  so  far  as  to  be  felt  in  the  rectum,  like  the 
vaginal  portion  of  the  cervix,  or  be  mistaken  for  a  prolapse  of  the 
rectum. 

Intussusceptions  which  are  not  of  the  ileo-c^ecal  varietv  are,  as 
a  rule,  caused  by  Meckel's  diverticuUun  or  innocent  tnniours  of  the  bowel. 
In  both  cases  the  upper  portion  of  the  intestine  with  the  tumour,  or 
with  the  inverted  diverticulum,  is  dragged  into  the  lower  portion. 
I  once  saw  the  characteristic  etiologv  well  exemplified  in  a  little  boy ; 
the  lower  portion  of  intestine  was  fixed  bv  tubercular  mesenteric 
glands,  the  upper,  forming  the  intussusception,  was,  however,  free. 
This  corresponds  to  the  condition  at  the  ileo-cjecal  valve,  where  the 
inore  movable  portion  of  the  intestine  becomes  mverted  into  a  less 
movable  portion. 

We  have  mentioned  the  passage  of  blood-stained  liquid  as  an 
important  sign  of  intussusception.  The  same  symptom  occurs  in 
infarction  of  the  bowel,  caused  by  blocking  of  a  blood-vessel,  which  is 
usually  accompanied  by  the  symptoms  of  sudden  intestinal  obstruc- 
tion. The  simultaneous  vomiting  of  blood-stained  material  points  to 
infarction. 

(4)   Volvulus. 

There  is  a  geographical  indication  which  points  to  volvulus  as 
the  diagnosis  of  the  form  of  intestinal  obstruction.  In  most  countries, 
neither  the  student  nor  surgeon  sees  manv  instances  of  this  condition, 
but  in  Russia,  especiallv  in  the  Baltic  Provinces,  volvulus  is  the  most 
frequent  variety  of  obstruction  brought  mto  hospital. 

Gruber  states  that  this  is  due  to  the  greater  length  of  the  Russian 
intestine  ;  others  attribute  it  to  the  abundant  dietarv  of  potatoes. 
I  know  many  places  where  the  potato  is  a  great  favourite,  but  where 
volvulus  is  almost  unknown.  Gruber's  view  is  also  stoutlv  contested. 
Indeed,  volvulus  is  more  likely  to  be  due  to  congenital  or  acquired 
abnormalities  in  the  mesentery,  which  permit  a  more  extensive  move- 
ment of  some  parts  of  the  intestine,  than  to  the  length  of  the  bowel  in 
metres.  To  allow  of  the  twisting  of  the  bowel  the  mesentery  requires 
a  certain  amount  of  hidependence,  which  is  given  it  by  a  long 
mesenterv  with  a  narrow  attachment.  Such  a  condition  is  only 
normal  in  the  sigmoid,  and  it  can  be  increased  by  the  greater  develop- 
ment of  this  coil  or  by  the  abnormal  approximation  of  its  lower 
extremity.  Sometimes  the  ileo-caecal  portion  is  provided  with  so 
profuse  a  mesentery  that  it  occasionally  twists  about  on  its  long  axis. 
Finally,  the  whole  of  the  siiuill  intestine,  either  itself  or  with  the  large 
■intestine,  may  possess  such  a  narrowly  attached  mesentery  that  the 
whole  bowel  is  capable  of  twisting  in  its  entirety.     I  saw  an  instance 


IXTESTIXAL    OBSTRUCTIOX  365 

of  this  ill  Kocher's  wards,  in  a  young  man  in  whom  the  torsion 
occurred  after  an  enormous  meal  of  cherries,  including  the  stones. 
The  occurrence  of  torsion  in  a  single  coil  of  small  intestine,  pre- 
supposes a  condition  in  which  it  has  been  subjected  to  traction  for 
a  considerable  time,  such  as  long  detention  in  a  hernial  sac,  or  the 
pull  of  an  intestinal  tumour. 

The  diagnosis  of  volvulus  of  the  sigmoid  is  verv  easy.  In  this 
condition  the  whole  abdomen  is  occupied  by  an  enormously  dis- 
tended coil,  with  its  head  in  the  upper  part,  and  with  its  more  or  less 
parallel  limbs,  which  can  be  distinctlv  felt,  and  even  seen.  Con- 
firmation is  afforded  by  the  impermeability  of  the  sigmoid  to  an 
injection  of  water.  An  ilco-ccecal  volvnlns  may  be  diagnosed  if, 
instead  of  a  long  and  distended  coil,  we  find  that  a  roundish  tvm- 
panitic  tumour  has  suddenly  formed,  with  a  seizure  of  vomiting,  and 
that  an  injection  of  water  can  be  successfully  given.  Volvulus  of 
the  ccliolc  siNdll  intestine  yields  the  symptoms  of  duodeno-jejunal 
obstruction,  plus  meteorism.  The  symptoms  of  volvulus  of  the 
small  and  large  intestine  together  are  about  the  same,  but  it  is 
impossible  to  inject  any  large  quantity  of  water  into  the  rectum. 
It  is  not  possible  to  differentiate  volvulus  of  a  single  coil  of  small 
intestine  from  obstruction  bv  a  band,  and  from  strangulation  into  a 
peritoneal  pouch. 

It  is  equally  impossible  to  detect  clinically  the  nodnles  which  are 
to  be  found  in  the  vicinity  of  a  volvulus,  and  which  depend  upon 
the  presence  of  Meckel's  diverticulum  and  the  bands  of  connective 
tissue  arising  from  it. 

The  foregoing  remarks  apply  to  volvulus  which  has  caused  com- 
plete obstruction  and  a  torsion  of  360°.  If  the  obstruction  is  in- 
complete (torsion  of  180'  to  270^),  the  symptoms  are  less  severe, 
and  often  disappear  spontaneously.  For  instance,  1  once  saw  the 
desired  evacuation  of  flatus  occur  after  a  long  journev,  at  the  verv 
moment  when  everything  was  about  to  be  expedited  for  an  operation. 
In  all  these  cases,  however,  the  diagnosis  is  only  a  matter  of  pure 
probabilitv, 

(5)  Strangulation  of  Internal   Hernias. 

Strangulation  into  a  congenital  peritoneal  pouch  is  one  of 
the  rare  causes  of  intestinal  obstruction  ;  but  sometimes  this 
diagnosis  is  suggested  by  the  demonstration  of  a  localized  distension. 
But  before  we  think  of  an  internal  hernia,  we  must  exclude 
strangnlation  of  an  cxterncd  liernia,  which  is  not  always  so  easy  to 
do  as  it  mav  appear,  especially  in  cases  of  pro-peritoneal  and  inter- 
muscular inguinal  herniae — hernia;  of  the  obturator  foramen,  lumbar, 
and  gluteal  herniae. 

I  recall  a  case  which  occurred  when  I  was  an  assistant.  A  young 
woman  was  sent  into  the  surgical  ward  after  suffering  from  obstruc- 
24A 


366      SURGICAL   DISEASES    OF    THE   ABDOMINAL   AND    PELVIC    VISCERA 

tion  for  several  clavs.  She  had  ah'eady  been  examined  for  hernia. 
but  none  had  been  detected.  Nevertheless  a  slight  resistance  at  the 
apex  of  the  internal  inguinal  ring  pointed  to  strangulation  of  an 
interstitial  hernia  ;  and  at  the  operation  it  was  found  that  the  contents 
of  the  hernia  were  alread_y  gangrenous  at  the  constricting  ring. 

An  error  in  connection  with  an  obturator  hernia  is  more  pardon- 
able. In  a  tvpical  case,  however,  the  pain  or  deep  pressure  below 
Poupart's  ligament,  and  the  neuralgia  of  the  obturator  nerve — 
probablv  called  old  rheumatism  by  the  patient — allows  the  diagnosis 
to  be  made  with  the  greatest  probability. 

But,  on  the  other  hand,  not  every  hernia  which  may  accidentally 
be  present,  even  if  irreducible,  must  be  credited  with  the  causation 
of  intestinal  obstruction.  If  the  hernia  is  not  tense,  and  if  there  is 
no  pain  on  pressure  over  its  neck,  it  has  nothing  to  do  with  the 
obstruction,  even  if  old  adhesions  have  rendered  it  irreducible. 

If  a  hernia  has  been  reduced  previously  to  the  occurrence  of 
obstruction,  the  neighbourhood  of  the  ring  must  be  examined.  Anv 
in-drawing  of  the  tissues,  or  indefinite  resistance,  or  pain  on  deep 
pressure  points  to  reduction  en  masse;  but  if  the  hernial  ring  is 
normal,  it  indicates  that  the  obstruction  has  some  other  origin. 

There  are  three  particularly  important  forms  of  internal  hernias  : 
[a)  Hernia  at  the  Foramen  of  Winslow.  When  strangulated,  this 
causes  a  tumour  behind  the  stomach.  It  has  often  been  operated 
on,  but  has  not  previously  been  diagnosed,  [b)  Diagnosis  ought  to 
be  more  possible  in  clnodeno-jejnnal  hernia. 

This  begins  at  Treitz's  pouch,  where  the  jejunum  passes  under 
the  transverse  colon.  The  pouch  opens  to  the  left  of  the  first  part 
of  the  jejunum,  and  is  directed  thence  obliquely  upwards  and  to  the 
left.  It  may  become  large  enough  to  contain  the  major  portion,  or, 
indeed,  the  whole  of  the  small  intestine.' 

The  svmptoms  of  these  hernia  are  intermittent  in  character:  but 
this  circumstance  is  common  to  several  other  forms  of  intestinal 
obstruction.  The  hernial  tumour  is  situated  in  the  epigastrium, 
rather  towards  the  left.  There  have  been  cases  recorded  wherein 
strangulation  has  occurred  in  a  similar  pouch  arising  from  the  right 
of  the  jejunum. 

(c)  The  third  typical  position  for  internal  hernice  is  in  the 
appendix  region. 

Of  the  various  pouches  described  by  anatomists  only  two  possess 
surgical  importance,  viz.,  the  ileo-appendicular,  which  is  situated 
betw'een  the  appendix  and  the  end  of  the  small  intestine  under  the 
region  of  Bauhin's  valve  ;  and  the  refro-ccBcal,  which  runs  laterally 
from  the  appendix  behind  the  caecum. 

In  both  forms  a  hernial  swelling  is  found  in  the  ileo-caecal  region, 
and  if  no  other  cause  for  the  inte>tinal  obstruction  is  evident,  it  is 
fair  to  assume  that  one  of  these  varieties  of  hernia  is  responsible. 


INTESTINAL    OBSTRUCTION  367 

We  shall  not  mention  any  of  the  rarer  forms  of  internal  hernia^ 
for  it  is  quite  impossible  to  diagnose  them  clinically.  This  applies  to 
strangulation  in  openings  of  the  mesentery,  omentum,  or  broad 
ligament. 

Diaphragmatic  hernise  are  seldom  suspected  before  operation, 
unless  a  previous  injury  to  the  diaphragm  has  suggested  its  proba- 
bility. A  tympanitic  note  or  dulness  over  the  left  lower  lobe  and 
marked  dysphagia  might  arouse  suspicion.  These  hernise  are  either 
on  the  left  side,  or  in  a  space  in  the  diaphragmatic  attachment  to  both 
sides  of  the  sternum  (Alorgagni's  space).  An  X-ray  examination 
after  a  bismuth  meal  furnishes  the  best  means  of  diagnosis. 


(6)  Spastic  Obstruction. 

Spastic  contractions  of  the  intestine,  without  any  evident  cause, 
sometimes  occur  after  abdominal  operations,  and  if  thev  persist  for 
any  length  of  time  lead  to  symptoms  of  intestinal  obstruction,  i.e., 
spastic  obstruction.     The  following  is  a  typical  case  : — 

A  young,  healthy  man  came  to  the  hospital  with  symptoms  of 
obstruction  high  up  in  the  small  intestine  and  a  temperature  of 
99"6'"'  F.  The  family  history  suggested  tubercle.  It  was  remarkab  e 
that  his  general  condition  remained  comparatively  good,  despite  the 
continuance  of  the  obstruction.  Operation  showed  that  a  coil  15  cm. 
in  length,  in  the  upper  part  of  the  small  intestine,  had  contracted  to 
a  thin  band.     When  the  spasm  relaxed  all  symptoms  vanished. 

It  is  possible  that  atropine  might  have  been  effective  here^  and 
permitted  the  making  of  a  diagnosis.  As  a  rule,  no  diagnosis  is  made 
until  the  abdomen  is  opened  ;  spastic  conditions  of  the  large  intes- 
tine are  more  frequent,  but  less  serious. 

Persistent  vomiting  must  not  be  confused  with  spastic  obstruction, 
because  hysteria  may  imitate  intestinal  obstruction.  But  in  that 
condition  the  physical  signs  do  not  correspond  with  the  general 
severity  of  the  symptoms  arranged  bv  the  patient.  If  it  is  pretended 
that  solid  faeces  are  vomited,  this  must  baffle  even  those  who  easily 
believe  what  they  are  told,  because  lumps  of  faeces  are  not  vomited 
by  anti-peristalsis.  They  get  into  the  vomit  in  a  much  simpler  wav. 
Relapses  have  been  observed  in  cases  wdierein  the  first  "  exhibition  " 
was  successful.  A  thorough  course  of  psychical  treatment  is  required 
to  prevent  these  relapses. 


368      SURGICAL    DISEASES    OF   THE   ABDOMINAL   AND   PELVIC    VISCERA 


CHAPTER  XLVIII. 

TUMOURS    AND    SWELLINGS    IN   THE   ABDOMINAL 

PARIETES. 

The  superficial  situation  of  a  tumour  or  swelling  indicates  that  it 
is  in  the  abdominal  wall  and  not  in  the  abdominal  cavity.  But  in 
very  thin  people  a  genuine  intra-abdominal  tumour  may  appear  to  be 
quite  superficial.  It  is,  therefore,  necessary  to  make  the  abdominal 
muscles  contract.  If  the  tumour  then  disappears,  it  must  be  situated 
within  the  abdominal  cavity,  or,  at  any  rate,  under  the  abdominal 
muscles.  If  however,  the  tumour  can  slill  be  felt,  and  at  the  same 
time  becomes  immovable,  it  is  obviously  connected  with  the  muscles 
or  fascia?.  Should  the  muscular  contraction  make  no  difference 
at  all,  the  tumour  is  situated  either  within  the  skin  or  subcutaneously. 


Fig.  157. — Chronic  abscess  in  epigastrium. 


In  order  to  obtain  a  correct  idea  amid  all  the  various  possibilities, 
it  is  very  important  to  note  whether  the  tumour  is  in  a  position 
"typical"  of  these  pathological  changes,  i.e.,  in  the  middle  line,  in 
the  inguinal  region,  in  the  lumbar  region,  or  whether  it  has  appeared 
at  some  other  point. 

(1)    THE    UPPER   ABDOMINAL    REGION. 

A  swelling  in  the  epigastric  region  may,  apart  from  exceptional 
rarities,  be  one  of  three  things  ;  viz.,  (i)  an  epigastric  abscess  ;  (2) 
subcutaneous  lipoma,  or  (3)  an  epigastric  hernia. 

If  the  swelling  is  acute,  and  presents  the  appearance  of  a  firm 
infiltration,  which,  after  a  little  while,  begins  to  soften  in  the  centre 


TUMOURS   AND    SWELLINGS    IN    THE    ABDOMINAL    PARIETES        369 


and  fluctuate,  there  is  no  difficulty  in  recognizing  an  epigastric 
abscess.  The  chronic  form,  in  which  the  skin  remains  unchanged 
for  a  considerable  time,  may  easily  give  rise  to  doubt.  But  even  in 
these  cases  the  wide  base  of  the  swelling  (fig.  157),  and  the  fluctuation 
which  is  rarely  absent,  suffice  to  indicate  an  abscess.  The  source  of 
infection  is  often  a  gastric  ulcer  which  has  become  adherent  to  the 
abdominal  wall,  and  which  has  protruded  after  suppuration. 

Theoretically,  one  would  imagine  that  these  abscesses  contain  gas, 
and  that  their  incision  would  lead  to  the  formation  of  a  gastric  fistula. 
But,  as  a  matter  of  fact, 
this  is  not  always  the  case, 
for  the  collection  of  pus 
may  have  no  connection 
with  the  interior  of  the 
stomach,  and  may  heal 
up  without  delay. 

Figure  157  represents 
such  a  case.  The  cause — - 
gastric  ulcer  —  was  only 
suspected  ;  it  was  not 
strictly  demonstrated. 

In  other  cases,  the 
swelling  may  be  an  ab- 
scess due  to  tubercle 
of  the  ribs  or  sternum. 
Rarely  it  may  be  a  bur- 
rowing abscess  making 
its  way  through  the  ab- 
dominal muscles. 

Subcutaneous  lipo- 
mata  differ  in  no  re- 
spect from  lipomata  in 
other  situations.  The 
accompanying  illustration 
(fig,  158)  shows  that  they 
may   attain    an    ordinary 

size.     They  are  distinguished  from  epigastric  hernias  and  from  sub- 
serous lipomata,  by  their  free  mobility  over  the  sheath  of  the  rectus. 

Epigastric  herniae  and  subserous  lipomata  are,  however,  much 
more  frequent. 

In  order  to  appreciate  their  origin  we  must  realize  that  a  large 
amount  of  fat  is  contained  in  the  upper  triangular  area  of  peritoneum 
which  has  its  apex  at  the  umbilicus.  The  first  stage  in  the  develop- 
ment of  a  hernia  is  the  protrusion  of  a  lobule  of  fat  through  an  oval 
slit,  which  is  always  situated  transversely  in  the  fibrous  tissue  of  the 
linea  alba.     If  this  lobule  continues  to  grow  after  it  has  become  free, 

24B 


Fig.  158. — Subcutaneous  lipoma  of  the  epigastrium. 


370      SURGICAL   DISEASES   OF   THE   ABDOMINAL   AXD    PELVIC   VISCERA 

it  develops  into  an  ordinary  subserous  lipoma  (fig.  i59rt).  As  it  grows 
it  usually  pulls  up  some  peritoneum  into  the  slit,  so  that  it  obtains  a 
pedicle  of  peritoneum,  which,  however,  contains  no  abdominal  viscus 
within  it  (fig.  1596).  If  this  peritoneal  protrusion  in  front  of  the  slit 
in  the  aponeurosis  develops  mto  a  hernial  sac,  into  which  omentum 
or  bowel  finds  its  way,  the  case  is  one  of  epigastric  fatty  hernia 
(fig  159,  c).  If,  finally,  the  hernial  development  is  greater  than 
the  fatty  proliferation,  the  case  is  one  of  ordinary  epigastric  hernia 
(fig.  159,  ^); 

The  differential  diagnosis,  in  these  conditions,  depends  to  a  great 
extent  on  the  question  of  reducibility.  If,  despite  patient  and  gentle 
pressure,  the  swelling  cannot  be  reduced  at  all,  and  if  we  are  told  that 


Fig.  159. — Epigastric  hernia  and  subserous  lipoma. 

(i)  Skin.     (2)  Rectus  sheath.     (3)  Subserous  fat.     (4)  Peritoneum. 
(a)  Subserous  lipoma,  after  breaking  through  sheath  of  rectus. 
(i)  ,,  ,,         with  some  peritoneum  pulled  up  into  fascial  slit. 

(c)  „  „         with  a  hernial  sac  containing  some  protruded  omentum.     (Epigastric  fatty  hernia.) 

{if)  Pure  epigastric  hernia,  without  lipoma. 

the  circumference  of  the  tumour  is  always  the  same,  the  case  is  one 
of  pure  subserous  lipoma,  an  illustration  of  which  is  given  in  fig.  i6o. 
If  the  tumour  becomes  large  under  the  influence  of  abdominal 
pressure,  but  always  permits  of  partial  reduction,  it  is  most  probably 
a  hernia,  but  the  possibility  of  subserous  lipoma  cannot  be  entirely 
excluded.  As  far  as  their  external  appearance  is  concerned,  they  both 
look  like  the  swelling  depicted  in  fig.  i6o.  The  hernia  seldom  attains 
the  size  illustrated  in  fig.  i6i. 

A  mass  of  omentum  adherent  to  a  hernia  may  resemble  a  lipoma, 
as  the  thickness  of  the  abdominal  wall  does  not  usually  permit  of 
differentiating  between  omentum  and  a  lipoma. 


TUMOURS   AXD    SWELLINGS    IX    THE    ABDOMINAL    PARIETES        371 


If  the  diagnosis  of 
epigastric  hernia  were 
always  made  in  time,  it 
would  prevent  many  so- 
called  "dyspeptics"  wast- 
ing years  on  treatment 
for  indigestion,  when  a 
simple  surgical  measure 
could  at  once  restore 
them  to  health.  The 
"  dyspepsia  "  is  caused 
by  the  pull  on  the  perito- 
neum, or  on  the  omen- 
tum firmly  grasped  within 
the  hernial  sac.  But,  on 
the  other  hand,  one  must 
not  overlook  a  cancer  of 
the  stomach,  because  there  happens 
to  be  an  epigastric  hernia  present. 
Both  the  abdominal  wall  and  the 
stomach  must  be  investigated. 

I  have,  several  times,  seen  the 
ligamentnm  teres  of  the  liver  in 
this  hernia,  a  circumstance  which, 
as  Graser  remarks,  is  not  without 
its  influence  on  the  symptoms  com- 
plained of. 

(2)  THE  UMBILICAL  REGION. 

If  we  find  that  a  newly-born 
infant  has  a  swelling  in  the  um- 
bilical region,  generally  with  a 
broad  base,  and  but  rarely  pedun- 
culated, in  which  the  intestinal 
contents  —  usually  the  liver  and 
bowel — can  be  seen  through  a  veil- 
like membrane,  the  case  is  clearly 
one  of  hernia  of  the  umbilical  cord 
(fig.  163).  It  is  quite  impossible  to 
mistake  this  for  any  other  condition, 
and  therefore  need  not  detain  us. 

If  the  umbilicus  projects  in  a 
semi-globular  form  and  eventually 
in  a  conical  or  cylindrical  shape,  in 


Fig.  160. — Subserous  lipoma  in  epigastrium. 


Fig.  161. — Large  epigastric  hernia. 


372       SURGICAL    DISEASES    OF   THE   ABDOMINAL  AND   PELVIC   VISCERA 

a    shrieking    little    cliild,    only    one    diagnosis    is    possible,    that    of 
umbilical  hernia. 

If  an  adult,  generally  over  forty,  presents  a  tumour,  varying  in 
size  from  a  pea  to  a  man's  head,  in  the  same  region,  the  same 
diagnosis  applies,  if  the  swelling  is,  at  least  partially,  reducible.  The 
principal  diagnostic  interest  in  these  cases,  is  not  so  much  concerned 


Fig.    162. — Multilocular  umbilical  hernia  in  cirrhosis  of  the  liver. 


with  the  nature  of  the  trouble,  as  with  certain  of  its  accompanying 
symptoms.  If  the  contents  are  reducible,  either  the  granular  feel  or 
the  gurgling  sound  will  indicate  omentum  or  intestine.  But  in  some 
umbilical  herniae  it  is  impossible  to  demonstrate  the  one  or  the  other. 
The  contents  are  easily  displaced  by  pressure,  but  neither  the  reduc- 
tion nor  the  refilling  is  accomplished   with  a   jerk,  which  suggests 


TUMOURS    AND    SWELLIXGS    IX    THE    AliDO.MINAL    PAKIETES 


37: 


that  the  contents  must  be  fluid.  On  careful  examination,  free  fluid 
"^vill  also  be  found  in  the  abdominal  cavity,  and  the  liver  may  exhibit 
signs  of  cirrhosis,  or  some  cause  for  the  ascites  may  be  discovered 
in  the  heart  or  kidnevs  (fig.  162). 

In  large  old-standing  cases  of  umbilical  hernia  (fig.  162)  it  can  be 
seen,  even  externallv,  that  they  consist  of  separate  loculi.  Some  of 
these  may  be  reducible  while  others  are  not.  It  sometimes  happens 
that  a  hard  and  tender  swelling  arises  in  one  of  these  loculi,  while 
the  rest  of  the  hernia  still  remains  reducible.  The  most  likely 
explanation  of  this  occurrence  is  the  strangulation  of  intestine  or 
omentimi  in   one  of  the  loculi. 

But  other  causes  are  conceiv.ible.  For  instance,  in  the  case  of  an 
old  woman,  whom  I  suspected  of  such  partial  strangulation,  the 
localized  inflammatory  symptoms  were  really  caused  by  a  tubercular 


Fig.  163. — Hernia  of  the  umbilical  cord  in  an  infant. 


peritonitis  which  had  involved  tlie  hernial  sac.  This  might  verv 
well  occur  also  with  cancerous  peritonitis.  On  another  occasion 
I  witnessed  a  peritonitis,  which  arose  from  the  suppuration  of  an 
ovarian  cyst,  involve  a  large  omental  hernia  and  form  a  circumscribed 
abscess.  An  inflamed  gall-bladder,  and  even  the  appendix  has  been 
found  in  an   umbilical  hernia. 

If  the  tumour  presenting  at  the  umbilicus  is  not  reducible  at  any 
stage  we  must  ascertain  whether  it  fluctuates,  or,  at  any  rate,  whether 
it  feels  elastic,  in  which  circumstances  it  mav  be  one  of  the  various 
cysts  occurring  in  this  region,  especially  a  dermoid  or  epidermoid. 
If  the  cyst  is  situated  in  or  beneath  the  abdominal  wall,  opposite  the 
bladder,  it  is  probably  connected  with  the  urachus  ;  if  directly  behind 
the  umbilicus,  with  the  vitelline  duct. 

Solid  timioiirs  are  u-uallv  secondar/  and  represent  metastases  or 
direct  extensions  of  cancer   within    the   ribdominal  cavity.      If,   how- 


374      SURGICAL    DISEASES    OF   THE    ABDOMINAL   AND    PELVIC    VISCERA 

ever,  such  a  causation  can  be  excluded,  they  must,  apart  from  rare 
exceptions,  be  regarded  as  primary  cancers  or  sarcomata  if  they  grow 
rapidly,  and  as  fibromata  if  their  growth  is  slow. 

The  primary  cancers  start  from  the  skin  and  appear  as  ulcers  with 
hard  margin  and  base,  or  as  cauliflower-like  papillomata.  Cancer  of 
the  umbilicus  mav  also  arise  from  intestinal  cpitheliuni,  which  has 
become  displaced  into  the  umbilical  scar.  Finally,  the  epithelium  of 
the  iiradius  may  undergo  cancerous  degeneration.  We  should  think 
of  this  origin,  if  the  cancerous  tumour  stretches  downward  from  the 
umbilicus  towards  the  bladder.  The  snb-nnihilical  abscess  may  also 
be  mentioned.  This  occupies  a  triangular  area  with  its  base  upwards 
under  the  umbilicus  and  behind  the  recti.  The  pus  organisms  reach 
this  space  from  the  viscera  of  the  lower  abdominal  cavity,  or  from 
the  abdommal  integuments.  The  course  of  this  abscess  is  either 
chronic  or  acute,  depending  upon  the  nature  of  the  organism — tubercle 
bacillus,  staphylococcus,  colon  bacillus,  &c. 

(3)   INGUINAL    REGION. 

Owing  to  the  presence  of  the  spermatic  cord,  the  round  ligament, 
and  the  vaginal  process  of  peritoneum,  the  inguinal  region  is  the  seat 
of  many  kinds  of  swelling,  which  we  shall  meet  with  later  on.  For 
the  moment  we  are  only  concerned  with  the  leading  features  of 
diagnosis  in  this  region. 

We  must  first  ascertain  whether  the  swelling  can  be  reduced,  or 
whether  its  contents  can  be  displaced.  If  so,  the  case  must  be  either 
a  hernia,  a  bilocular  or  communicating  hydrocele,  or  a  burrowing 
abscess.  If  an  intestinal  note  is  found  over  the  swelling,  or  if  it  feels 
granular  or  lumpylike  omentum,  there  is  no  doubt  about  it  being 
a  hernia.  The  same  applies,  if  its  reduction  is  accomplished  in  a 
sudden  manner.  But  if  it  is  only  displaced  gradually  and  the  swelling 
corresponds  accurately  to  the  direction  of  the  inguinal  canal,  we 
must  think  of  one  of  the  forms  of  hydrocele  just  mentioned.  If  the 
swelling  is  more  laterally  situated  and  can  only  be  incompletely  dis- 
placed, and  if,  in  addition,  it  is  painful  on  pressure,  we  should 
think  of  a  bun-owing  abscess  and  search  for  confirmation  in  the 
vertebral  column. 

Finally,  if  the  swelling  is  reducible,  but  feels  neither  like  intestine 
nor  omentum,  but  like  a  smooth  roundish  body,  the  case  is  one  of  an 
inguinal  testicle  or  a  prolapsed  ovary. 

If,  however,  the  swelling  is  irreducible,  but  is  soft  or  tensely  elastic 
in  consistence,  we  must  think,  according  to  its  position,  either  of  an 
enclosed  hydrocele  in  the  inguinal  canal,  or  of  a  burrowing  abscess 
which  admits  of  no  displacement.  In  this  connection  it  is  worth 
mentioning  that  there  a  so  such  a  condition  as  a  hydrocele  in  the 
female. 


TUMOURS   AND    SWELLINGS    LN    THE    ABDOMINAL    PARIETES 


)75 


A  solid  tumour  is  more  probably  an  inguinal  gland,  especially  if 
it  is  subcutaneous,  of  the  shape  of  a  bean,  and  multiple.  The  ex- 
amination of  the  appropriate  lymphatic  district  will  show  whether  its 
origin  is  due  to  cancer,  hard  or  soft  chancre,  or  merely  a  simple 
herpes  genitalis. 

Should  no  such  origin  be  discoverable,  there  arises  the  question 
of  tubercle  or  Ivniphadeuonia,  for  the  latter  occasionally  starts  in  the 
inguinal  region.  We  have  already  discussed  the  differential  diagnosis 
HI  the  chapter  on  Tumours  of  the  Neck. 

If  the  swelling  consists  of  a  large 
uniform  tumour  which  has  grown  rapidly 
and  soon  becomes  immovable,  it  must 
be  regarded  as  a  sarcoma.  If  its  size 
increases  but  slowly,  it  must  be  regarded 
as  a  fibroma  of  the  abdominal  wall. 
A  movable,  spindle-shaped  or  cylindri- 
cal, hard  tumour  in  the  ingumal  canal 
of  a  woman  is  most  probably  a  fibro- 
myoma  of  the  round  ligament. 

(4)    LUMBAR    REGION. 

A  swelling  which  appears  in  the  lum- 
bar region  during  an  abdominal  strain 
is  a  lumbar  hernia,  whether  it  is  spon- 
taneously reducible  or  only  by  pressure. 

There  are  two  sites  for  hernial  pro- 
trusion in  the  lumbar  region.  One  is 
at  the  outer  border  of  the  quadratus 
lumborum,  just  imder  the  tweh'th  rib 
(Gryrjfeldt),  the  other  is  at  Petit's  triangle, 
the  three  sides  of  which  are  formed 
by  the  iliac  crest,  the  external  abdom- 
inal oblique,  and  the  latissimus  dorsi. 
Congenital  lacunae  in  the  muscles  seem, 
however,  to  be  of  more  importance. 

In  certain  rare  cases  of  infantile  paralysis  the  muscular  atrophy 
may  affect  the  muscles  in  front  of  the  quadratus  lumborum,  which 
become  paralysed  and  atrophic  over  a  dehnite  limited  extent.  The 
border  of  the  paralysed  area  is  so  sharp  that  it  imparts  the  same 
sensation  as  the  boundaries  of  a  genuine  hernial  ring.  Pig.  164 
depicts  such  a  case;  one  of  the  first  in  which  this  paralvsis  was 
shown  to  be  the  cause  of  the  pseudo-hernia. 

A  lumbar  swelling,  which  is  onlv  partially  reducible  after  steady 
pressure,  is  either  a  burrowing  abscess  or  a  tubercular  perinephritic 
abscess,  which  has  burst  through,  behind.  An  examination  of  the 
urine  will  differentiate  between  these  two  possibihties.     If  the  tumour 


Fig.  164.  —  Pseudo-hernia  in  the 
lumbar  region,  due  to  localized 
muscular  paralysis. 


3/6      SURGICAL   DISEASES   OF   THE    ABDOMINAL   AND    PELVIC   VISCERA 

is  soft,  but  quite  irreducible,  with  a  perfectly  smooth  surface,  and 
a  more  or  less  distinct  fluctuation,  it  is  a  cold  abscess  with  the 
origin  just  mentioned,  or  it  may  have  started  in  one  of  the  lower  ribs. 
If  it  has  a  lobulated  structure,  and  its  situation  is  definitely  sub- 
cutaneous, it  must  be  regarded  as  a  lipoma. 

(5)  SWELLINGS  AND  TUMOURS   IN   ATYPICAL  POSITIONS. 

If  a  swelling  is  not  in  one  of  the  usual  typical  positions,  but 
still  possesses  the  features  of  a  hernia,  we  are  bound  to  assume  a 
traumatic  origin  for  it.  Such  trauma  is  almost  always  a  laparotomy 
wound,  which  at  once  reveals  itself  by  the  scar.     It  is  much  more  rare 


Fig.  165. — Tuberculosis  of  the  abdominal  wall. 

for  such  localized  destruction  of  the  abdominal  wall  to  be  due  to 
accidental  injuries  or  inflammatory  processes. 

The  very  rare  abdominal  hernia  which  appears  at  the  outer  border 
of  the  rectus  muscle,  in  the  vicinity  of  the  linea  semicircularis,  should 
be  distinguished  from  other  abdominal  hernia  because  of  its  rather 
typical  occurrence. 

Irreducible  tumours,  connected  with  the  skin  and  suhcutaneoiis 
fissile,  are  lipomata,  more  rarely  soft  fibromata,  occasionally  also 
naevi  which  have  become  sarcomatous.  (See  under  "Tumours  of 
the  Back,"  Chapter    XXXI.)     If  they  are  more  deeply  situated    and 


ABDOMINAL   SINUSES  377 

are  connected  with  the  luuscular  layer  of  the  abdominal  ivall,  they 
may  be  either  fibromata  of  the  abdominal  integument,  which  have 
been  previously  mentioned,  or  tubercle  of  the  muscle,  which  not 
infrequently  attacks  the  abdominal  muscles.  The  female  sex,  and 
a  spindle-shaped,  sharply  defined,  uniformly  hard  tumour  are  points 
in  favour  of  a  fibroma ;  but  an  irregular  shape,  partial  softening, 
slight  mobility  and  relaxation  of  the  abdominal  integuments  are 
points  in  favour  of  tubercle  (fig.  165). 

If  a  hard  fibrous  tumour  appear  in  the  operation  area  months, 
or  even  years,  after  an  abdominal  operation — e.g.,  the  radical  opeiation 
for  hernia — we  shall  probably  find  a  few  threads  of  silk  floating 
about  in  a  little  deeply  situated  pus,  or  embedded  in  granulations, 
as  first  shown  by  Schloffer. 

Experience  shows  that  a  hard,  board-like  swelling  in  the  ileo-caecal 
region,  which  gradually  reddens  the  skin  and  eventually  produces 
sinuses,  is  most  probably  actinomycosis,  originating  in  the  caecum. 
Every  localized  inflammatory  swelling  of  the  abdominal  wall  should 
be  referred  to  infection  breaking  through  from  the  intestine,  but 
it  is  more  likely  to  be  tubercle  or  cancer  than  actinomycosis,  except 
in  the  ileo-caecal  region. 


CHAPTER   XLIX. 
ABDOMINAL    SINUSES. 

A  SINUS  may  arise  anywhere  in  the  abdominal  wall,  as  the  result 
of  an  abscess  or  a  malignant  growth  breaking  through.  There  is, 
however,  nothing  typical  about  such  an  occurrence.  We  will,  there- 
fore, confine  ourselves  here  to  sinuses  whose  position  and  charac- 
teristics are  of  diagnostic  significance. 

Most  sinuses  originate  at  the  umbilicus,  the  point  at  which  most 
abdominal  organs  meet  in  their  embryological  history,  and  which 
is  the  weakest  spot  in  the  abdominal  wall,  as  far  as  later  morbid 
processes  are  concerned. 

(1)  Congenital  umbilical  sinuses  may  be  connected  through  a 
patent  vitelline  duct  with  the  small  intestine,  or  through  a  patent 
urachus  with  the  bladder.  The  distinction  is  quite  easy,  because 
in  the  former  cases  fjecal  matter  escapes  from  the  sinus,  in  the 
latter,  urine.  It  is  somewhat  more  difficult  to  account  for  a  third 
umbilical  sinus,  which  discharges  neither  fasces  nor  urine,  but  a 
thin  mucoid  fluid.     This  variety  leads  either  into  a  piece  of  urachus, 


378      SURGICAL   DISEASES   OF   THE   ABDOMINAL   AND   PELVIC   VISCERA 

which  is  open  at  the  umbilicus  but  is  closed  towards  the  bladder, 
or  into  a  piece  of  vitelline  duct,  closed  towards  the  intestine.  As  far 
as  observations  have  gone  hitherto,  the  latter  is  the  more  frequent 
termination. 

These  incomplete  vitelline  sinuses  discharge  a  peculiar  acid 
secretion  like  the  gastric  juice,  and  were  formerly  regarded  as 
gastric  fistulas.  The  secretion  sometimes  causes  digestion  of  the  skin, 
and  ulcerates  the  area  surrounding  the  sinus. 

(2)  We  diagnose  an  acquired  umbilical  sinus  from  the  nature 
of  the  secretion,  and  thus  differentiate  pure  suppurating  fistulae, 
biliary  fistulae,  faecal  fistulas,  and  urinary  fistulae. 

(a)  Suppurating  fistuhe  usually  result  from  an  intra-abdominal 
inflammatory  process,  which  has  burst  through  the  abdominal  wall 
at  the  umbilicus,  i.e.,  its  weakest  spot.  As  a  rule  it  occurs  in 
peritonitis  which  has  become  chronic  (pneumococcus  infection, 
fig.  142).  A  localized  tubercular  peritonitis  may  exceptionally  burst 
through  at  the  umbilicus. 

Rupture  of  a  suppurating  hydatid  or  ovarian  cyst  may  be 
mentioned  as  a  very  rare  cause  of  suppurating  fistula  at  the  umbilicus. 
Empvema  of  the  gall-bladder  may  occasionally  open  at  the  umbilicus 
and  cause  a  suppurating  fistula,  as  long  as  the  cystic  duct  remains 
closed.  Finally,  the  sub-umbilical  abscess  at  the  back  of  the 
abdominal  wall,  previously  referred  to,  may  escape  through  the 
umbilicus. 

A  carefully  passed  probe  will  attain  a  certain  depth  in  all  these 
forms  of  umbilical  sinus.  But  if,  after  several  attempts,  the  probe 
does  not  reach  beyond  the  umbilicus,  the  case  is  probably  one  of 
an  umbilical  concretion  enclosed  in  a  cutaneous  pouch,  or  a  ruptured 
sebaceous  cyst  or  dermoid  of  the  umbilicus,  or,  finally,  a  very  small 
sub-umbilical  abscess.  If  the  microscopic  examination  of  the  secre- 
tion reveals  chiefly  detritus  and  epithelial  cells,  one  of  the  first  three 
possibilities  should  be  thought  of,  but  its  accurate  differentiation 
cannot  be  made  out  until  the  sinus  is  laid  open.  If  the  secretion 
is  entirely  purulent  we  should  think  of  sub-umbilical  abscess. 

(b)  Biliary  fistulcv  arise  in  the  manner  previously  indicated  if 
the  cystic  duct  regains  its  patency  after  rupture  of  the  empyema  of  the 
gall-bladder. 

(c)  Gastric  and  intestinal  fistnlce,  which  are  easily  recognizable  by 
the  character  of  their  secretion,  are  caused  by  rupture  of  an  ulcer. 
In  the  case  of  the  stomach,  this  is  either  a  simple  gastric  ulcer  or 
cancer  ;  in  the  case  of  the  intestine,  it  may  be  due  to  cancer  or 
tubercle,  but  it  may  also  be  the  consequence  of  a  strangulated 
gangrenous  umbilical  hernia.  The  latter  origin  would  at  once  be 
clear  from  the  history. 

{d)   Urinary  fistula;  may  arise   through   extension    of   cystitis  into 


EXTERNAL    INGUINAL    HERNIA  379 

a  persistent  urachus,  with  eventual  rupture  at  the  umbihcus.  In 
other  cases  they  may  be  due  to  the  rupture  of  a  phlegmon  of  the 
abdominal  wall  caused  by  infiltration  of  urine. 

Typical  sinuses  are  also  found  in  the  inguinal  region  arising  from 
a  strangulated  hernia,  or  through  rupture  of  a  burrowing  abscess. 
The  character  of  the  discharge  from  the  sinus  (intestinal  contents 
or  pus)  and  the  previous  history  will  lead  to  a  correct  conclusion. 
In  addition,  a  sinus  situated  very  much  at  the  side  points  to  a 
burrowing  abscess.  But  if  the  sinus  is  in  a  more  central  position, 
either  between  both  recti  or  at  the  outer  border  of  one  of  them, 
there  may  arise  a  question  of  tubercle  of  the  pubic  bone,  or  of 
osteomyelitis  with  a  sequestrum.  Finally,  urinary  fistula3  after 
strictures  may  occasionally  wander  into  the  lower  abdominal  region. 

We  shall  not  discuss  ectopia  vesicae,  because  this  malformation 
cannot  be   mistaken  for  anything  else. 


CHAPTER  L. 
EXTERNAL  INGUINAL  HERNIA. 

Although  abdominal  hernias  are  matters  of  daily  occurrence,  and 
the  more  common  forms  are  correctly  diagnosed  by  the  public  as 
well  as  by  the  profession,  nevertheless  there  are  some  points  worth 
referring  to,  even  in  this  region.  We  begin  with  some  observations 
on  the  subject  of  a  "tendency  to  hernia,"  an  expression  which  to 
many  people  conveys  no  clear  conception. 

A  tendency  to  liernia  implies  certain  anatomical  condilions,  ivliicli 
may  lead  to  tlie  development  of  liernia  zvlien-  the  inira-abdominal  pres- 
sure is  raised,  i.e.,  even  to  the  slightest  temporary  entrance  of  any  of  ttie 
abdominal  viscera  into  a  process  of  peritonenm.  A  tendency  to  hernia 
may  involve  either  the  peritoneum  or  the  muscular  wall  of  the 
abdomen,  or  both. 

In  the  former  case  the  hernial  sac  is  small,  very  narrow  and  con- 
genital, being  due  to  the  imperfect  obliteration  of  the  processus 
vaginalis  of  tiie  peritoneum.  The  sac  is  too  narrow  to  admit  any  of 
the  abdominal  contents  (fig.  i66,  a).  The  development  of  the  muscles 
and  aponeurosis  may  be  quite  normal. 

In  the  latter  case  the  primary  change  consists  of  a  congenital  or 
acquired  weakness  of  muscles  and  fascial,  combined  w-ith  abnormal 
width  of  the  canal.  Every  act  of  coughing  presses  the  peritoneum, 
which  is  quite  closed  in  the  normal  manner,  against  the  unresisting 
internal  inguinal  ring,  and  causes  it  to  bulge  therein  in  a  conical 
form  (Kocher)  (fig.   i66,  b). 

25 


380      SURGICAL   DISEASES   OF   THE   ABDOMINAL   AND    PELVIC   VISCERA 

Finally,  both  conditions,  patent  processus  vaginalis  and  weak 
abdominal  walls,  may  occur  together. 

The  first  variety  of  "tendency  to  hernia"  cannot  be  demonstrated 
clinically  as  long  as  it  is  really  only  a  "tendency."  In  the  second 
variety  of  tendency  the  finger  introduced  into  the  inguinal  canal 
meets  with  the  well-known  impulse.  This  also  applies  to  the  com- 
bined variety,  in  which  the  "tendency"  rapidly  develops  into  a 
complete    hernia. 

There  is  no  doubt  that  the  congenital  tendency  to  hernia,  in 
the  form  depicted  in  fig.  166,  is  of  more  importance  than  the  acquired 
form,  but  this  is  no  justification  for  throwing  any  doubt  upon  the 
occurrence  of  the  latter. 

After  these  preliminary  remarks  we  now  turn  to  simple  inguinal 
hernia,  dealing  first  with  the  form  which  manifests  nothing  abnormal 
externall}^ 

(1)   DIAGNOSIS  IN  THE  ABSENCE  OF  A  HERNIAL 
SWELLING. 

To  examine  a  patient  for  hernia,  when  there  is  nothing  visible 
externally,  we  place  him  in  a  standing  posture,  with  his  legs  some- 
what separated,  and  direct  him  to  cough  or  press,  while  we  see  whether 
any  bulging  occurs.  If  the  whole  region  above  Poupart's  ligament 
becomes  pushed  forward  in  a  diffuse  manner,  without  any  visceral 
projection,  we  term  the  condition  "  soft  groin,"  i.e.,  a  congenital  or 
acquired  weakness  of  the  abdominal  wall.  But  if,  on  feeling  both 
groins  simultaneously,  we  appreciate  a  definitely  circumscribed 
impulse  on  one  side  we  may  conclude  that  a  hernia  is  beginning. 
Then  we  invaginate  the  scrotal  skin  into  the  ingumal  canal  with  the 
index  finger,  and  press  again.  In  normal  conditions  this  manoeuvre 
causes  the  posterior  superior  limit  of  the  inguinal  canal  to  become 
more  tense  owing  to  contraction  of  the  internal  oblique  ;  but  if  there 
is  any  tendency  to  hernia  a  soft  bulging  forwards  of  the  posterior 
wall  of  the  canal  will  be    felt. 

If  any  of  the  intestinal  contents  have  entered  the  canal  it  is  no 
longer  a  matter  of  tendency  to  hernia,  but  of  a  hernia  actually  begun. 
It  is  advisable  to  let  the  patient  lie  down  before  making  any  further 
examination  into  the  direction  and  range  of  the  inguinal  canal.  If  the 
abdominal  contents  remain  within  the  canal  after  the  abdominal 
pressure  has  been  relaxed,  but  do  not  emerge  from  the  external 
ring  on  subsequent  coughing,  the  case  is  one  of  intestinal,  or,  better, 
of  inter-muscular  hernia. 

It  sometimes  happens  that  we  are  unable  to  secure  any  exit  of 
intestine  at  the  first  examination^  although  a  hernia  is  present.  In 
such  cases  we  may  derive  some  assistance   from  carefully  feeling  the 


EXTERNAL   INGUINAL   HERNIA 


381 


spermatic  cord.  If  it  is  definitely  thickened  on  one  side,  and  if  it 
is  possible  to  demonstrate  the  presence  of  a  narrow  transverse  pad, 
we  may  assume  the  existence  of  a  hernial  sac.  This  narrow  pad 
represents  the  ring-shaped  thickening  which  is  often  observed  in 
older  hernias,  and  which  had  been  situated  previously  at  the  internal 
inguinal  ring.      If   this  examination    is    inconclusive,  it   is   necessary 


Fig.  166.  — Relations  between  external  inguinal  hernia  and  the  abdominal  wall. 

(1)  Peritoneum.     (2)  Spermatic  cord.     (3)  Muscular  layer  (especially  internal  oblique). 
(4)  Aponeurosis  of  external  oblique.     (5)  Skin. 


{a)  Congenital  tendency  to  hernia. 

(/))  Acquired  tendency  to  hernia  with  weak  muscles. 

(c)  Fully  developed  inguinal  scrotal  hernia. 

(rf)  Pro-peritoneal  hernia. 


(e)  Intermuscular  hernia  (interstitial). 
(/")  Intermuscular  bi-locular  hernia. 
(^)  Subcutaneous  hernia. 


to  repeat  the  examination  by  making  a  patient  lift  a  heavy  weight, 
with  his  legs  outspread  and  his  body  bent  backwards. 

It  is  not  easy  to  demonstrate  the  presence  of  an  inguinal  hernia  in 
females  if  it  does  not  happen  to  be  down  at  the  time  of  examination. 
The  narrowness  of  the  inguinal  canal   does  not  allow  of  the  intro- 
25A 


382      SURGICAL   DISEASES    OF    THE    ABDOMIXAI.   AND    PELVIC    VISCERA 

duction  of  the  finger,  as  in  the  case  of  a  male.  It  no  impulse  is  seen 
or  felt  on  coughing,  we  must  endeavour  to  feel  the  hernial  ^ac,  which 
can  be  done  more  easily  than  in  bovs  or  men,  because  the  round 
ligament  in  females  disturbs  us  less  than  the  spermatic  coi'd  m  males. 
We  place  the  index  fingers  on  each  side,  median  to  the  external 
inguinal  ring  over  the  pubic  bone  and  move  the  skin  over  the  latter, 
upwards  and  downwards,  comparing  the  two  sides.  If  a  hernial  sac 
is  present,  there  is  felt,  not  so  much  a  thickening  of  tissue  as  fine 
friction  caused  by  the  gliding  of  one  serous  surface  on  the  other.  If 
this  sign  can  be  demonstrated  at  repeated  examinations,  we  may  be 
quite  secure  in  our  diagnosis  of  inguinal  hernia. 


Fig.  167. — External  inguinal  hernia  (at 
external  abdominal  ring;. 


Fig.  168.  —  External  inguinal  hernia,  extending  into  the 
labium. 


This  simple  examination  will  sometimes  explain  severe  attacks  of 
abdominal  pain  which  have  been  attributed  to  appendicitis,  movable 
kidnev,  and  other  possibilities  before  the  di-xovery  of  the  hernia. 


(2)   DIAGNOSIS  OF  INGUINAL  HERNIAL  SWELLINGS. 

If  an  abnormal  -welling  bulges  forward  in  the  inguinal  region,  the 
examination  is  a  much  -nnpler  matter.  If  the  swelling  can  be  dis- 
placed backwards,  and  probably  also  yields  an  intestinal  note  on 
percussion,  it  is  an  interparietal  intestinal  hernia.     If  it  is  irreducible 


EXTERNAL    INGUINAL    HERNIA 


3«3 


but  yields  a  definite  intestinal  note,  the  diagnosis  is  the  same.  If  the 
swelling,  whether  reducible  or  not,  feels  like  a  soft  granular  mass,  it  is 
an  interparietal  omental  hernia.  But 
if,  on  the  other  hand,  we  define 
clearly  a  smooth,  roundish  bodv,  it 
must  be  an  inguinal  testicle  in  a 
male,  an  ovarian  hernia  in  a  female. 
Every  now  and  then,  such  a 
swelling  is  a  testicle,  although  the 
patient  has  a  plait  and  bears  a  girl's 
name.  A  pseudo  -  hennaphrodite  is 
proclaimed  by  a  somewhat  enlarged 
clitoris  (fig.  169),  but  possessing  both 
testicles  and  a  vagina,  the  patient  is 
too  much  of  a  male  to  be  a  woman, 
and  too  much  of  a  female  to  be  a 
man.  It  is  fortunate  if  this  state  of 
affairs  is  discovered  before  marriage 
is  contracted.  Some  of  these  pseudo- 
hermaphrodites celebrate  the  dis- 
covery of  their  sex  by  indulgence  in 
tobacco  and  alcohol  ;  others,  de- 
spite their  testicles,  retain  the  sen- 
sitiveness of  the  female  and  remain  true  to  their  frocks. 


Fig.  169. — Genitalia  of  a  male  pseudo- 
hermaphrodite, wiih  a  vagina,  and  with 
testicles  in  a  hernial  sac. 


Fig.    170.— External   inguinal    hernia    with     a    divided     Fig.  171.— Bilateral  burrowing  abscess  due  to  spii 
sac    (one    portion  being    labial,   the   other    intermuscular,  caries, 

filling  and  emptying  separately). 

25B 


384      SURGICAL    DISEASES    OF    THE    ABDOMINAL    AND    PELVIC   VISCERA 

The  detection  of  an  inguinal  testicle  does  not,  of  course,  exclude 
a  hernia  ;  indeed  it  renders  the  presence  of  a  hernia  very  probable. 

These  herniae  may  be  divided  into  three  main  forms,  according  to 
their  position  : — • 

(i)  Pro-peritoneal  hernia,  situated  immediately  under  the  parietal 
serous  membrane  (fig.  166,  d). 

(2)  Inter-niusciilar  hernia,  in  the  area  of  the  muscular  abdominal 
\vall,  generally  between  the  internal  oblique  muscle  and  the  apo- 
neurosis of  the  external  oblique.  (Interstitial  hernia  in  a  narrow 
sense;  subaponeurotic  hernia.)     (Fig.  166,  e  and/,  and  fig.  174.) 

(3)  Subcutaneous  hernia,  between  the  aponeurosis  of  the  external 
oblique  and  the  skin  (inguino-superficial  hernia,  sub-fascial  hernia). 
(Fig.  166,  g,  and  fig.  174.) 


Fig.  172. — Right-sided  burrowing  abscess,  admitted  into  hospital  as  "  hernia.' 


All  these  herniae  may  occur  in  the  form  of  herniae  with  divided 
sacs,  which  unite   into  one  hernial    sac    in  the  scrotum   or  labium. 
They  all  occur,  but  much  more  rarely,  in  the  female  sex,  both  in  the 
simple  form  or  with  divided  sacs  (fig.  170). 

In  males  they  are  often  associated  with  a  retained  inguinal  testicle. 
If  the  hernial  sac  is  of  the  subdivided  variety  the  testicle  is  often 
found  lying  in  the  upper  interparietal  portion. 

As  far  as  the  clinical  diagnosis  of  these  various  forms  is  concerned, 
tlie  pro-peritoneal  variety  is,  as  a  rule,  detected  first  when  it  becomes 
strangulated.  The  symptoms  are  those  of  internal  strangulation,  and 
a  roundish    resistance   can   be    felt    deep  down    behind   the  internal 


EXTERNAL   IXGUIXAL    HERXIA 


3^0 


inguinal  ring.  The  diagnosis  of  tlie  intennuscnlar  and  the  much 
rarer  snbcntaneons  varieties,  has  ah-eady  been  referred  to  in  common  ; 
but  their  differentiation  is  of  some  interest.  For  this  purpose,  the 
patient  is  directed  to  sit  up  without  supporting  himself  by  his  arms. 
If  the  aponeurosis  of  the  external  oblique  then  becomes  tense  over  the 
hernia,  the  latter  is  intermuscular  (fig.  174)  ;  in  other  cases  it  is  sub- 
cutaneous (fig.  175).  In  this  illustration  the  laxity  of  the  hernia 
indicates  its  subcutaneous  position  at  the  first  glance. 

The  following  case  is  typical  of  a  hernia  with  a  divided  sac  : — 
I  operated  on  a  man,  aged  68,  for  what  was  apparently  an  ordinary 
scrotal  hernia,  without  opening  the  inguinal  canal,  but  I  excised  the 
sac  as  high  up  as  possible.  All  went  well  until  the  patient  stated, 
three  weeks  subsequently,  that  the  hernia  had  returned.  As  a  matter 
of  facr,  protrusion  of  the  intestine  could  be  seen  above  the  internal 
inguinal  ring,  when  the  patient  coughed.     A  second  operation  revealed 


Fig.  173. — Hydrocele  ot  spermatic  cord. 


an  intermuscular  hernial  sac  running  laterally  under  the  aponeurosis 
of  tiie  external  oblique.  It  was  quite  as  large  as  its  scrotal  off- 
shoot, which  had  been  removed  three  weeks  previously,  but  was 
overlooked  at  the  operation,  because  it  had  not  been  felt  at  the 
previous  examination. 

Simple  as  the  diagnosis  of  interparietal  hernia  would  appear  to  be 
from  the  foregoing  remarks,  nevertheless  mistakes  do  occur.  Femoral 
herni^e,  with  processes  extending  over  Poupart's  ligament,  are  especially 
liable  to  be  mistaken  for  inguinal  hernins  and  vice  versa  (figs.  186  and 
187).     But  it  is  not  only  with  other  hernijc  that  confusion   arises,  but 


386      SURGICAL   DISEASES   OF   THE   ABDOMINAL   AND    PELVIC   VISCERA 


also  with  other  diseases.  Thus  trusses  have  been  ordered  for  bur- 
rowing abscesses,  and  not  by  quacks  only,  for  medical  practitioners 
sometimes  neglect  to  make 
an  examination  from  mis- 
placed motives  of  delicacy, 
or  conduct  it  so  indifferent- 
ly that  it  is  quite  useless. 

Such  errors  are  easily 
avoided  by  careful  exam- 
ination. As  a  rule,  a  spinal 
abscess  shows  fluctuation ; 
a  hernia  does  not.  It  is 
true  that  the  pus  can  some- 
times be  displaced,  but  this 
only  occurs  gradually  after 
steady  pressure,  and  not 
suddenly  with  a  gurgle,  as 
in  the  case  of  the  intestine. 
When  the  pressure  is  re- 
laxed the  swelling  gradually 
returns  without  any  strain- 
ing, whereas  a  hernia  re- 
quires    some     change     of 


Fig.  174. — Intermuscular  inguinal  hernia,  under  the 
aponeurosis  of  the  external  oblique. 


Fig.  175. — Subcutaneous  inguinal  hernia  (H.  inguino    Fig.  176.  — External  inguinal  hernia,  just  come  through 
superficialis)  situated  under  the  skin.  the  external  ring. 


EXTERNAL    INGUINAL    HERNIA 


387 


posture  or  the  straining  of  abdominal  pressure  before  it  makes  its 
re-appearance.  Finally,  most  burrowing  abscesses  are  situated  more 
laterally  than  inguinal  herniae  usually  are  (figs.  171  and  172). 


Fig.    177.  —  Diagrammatic  representation  of  the  relations  between   the  vaginal  process  of 
peritoneum,  in  congenital  and  acquired  hernia;  and  in  hydrocele. 


(a)  Normal  obliteration  of  the  process,  i 
(i)  Partial  patency  of  the  process.     Funicular  hernia, 
(c)  Complete  patency  of  the  process.    Te=;ticular  hernia. 
((^)  ,,  ,,  „  ,,  with  narrow  neck, 

communicating  hydrocele. 
(e)  Patency  in  centre  of  process.     Funicular  hyf^rocele. 
(yO  Patency  at  lower  part.     Testicular  hj'drocele. 
(?•)  Outgrowth  of  7^  upwards.     Biloculat  hydrocele. 
(/?)  Combination  of  t?  and  X     Funicular  and  testicular 
hydrocele. 


(0  Combination    of  /'   and  /.     Funicular    hernia   and 

testicular  hydrocele, 
(/t)  Acquired  funicular  hernia. 
(0  ,,  , ,,  ,,       reaching   as   far   as    the 

testicle,    and   imitating  (c)  congenital  testicular 

hernia. 
(ot)  Combination    of  _/"  and    i:      Acquired    funicular 

hernia,    and    congenital   or    acquired    testicular 

hydrocele. 


(3)    DIAGNOSIS    OF    LABIAL   AND    SCROTAL    HERNI/E. 

A  swelling  situated  within  the  scrotum  or  labium  can  only  be  a 
hernia  if  it  has  a  pedicle  running  in  the  inguinal  canal.  If  this  be 
not  the  case  (fig.  178),  there  is  no  hernia.  If,  however,  there  be  such 
a  pedicle,  we  must  see  whether  the  swelling  is  reducible  (fig.  179). 
If  the  swelling  can  be  displaced  backwards,  possibly  with  a  buzzing 
or  gurgling  sound,  the  case  is  one  of  hernia.  If  the  reduction  is 
slow  and  requires  steady  pressure,  the  condition  is  usually  one  of 
communicating  hydrocele,  and  only  rarely  a  bilocular  hydrocele  with 
the  second  sac  in  the  abdomen. 


388      SURGICAL   DISEASES    OF   THE   ABDOMINAL   AND    PELVIC   VISCERA 

A  varicocele  is  apparently  reducible,  but  the  filling  up  of  the 
swelling  like  a  handful  of  earthworms,  when  the  patient  stands,  and 
its  immediate  relaxation  when  he  lies  down,  without,  however,  any  of 
its  contents  actually  receding,  ought  to  exclude  the  possibility  of  any 
confusion.  If  the  swelling  has  a  pedicle,  but  is  irreducible,  the  case 
may  be  one  of  testicular  hydrocele  reaching  as  far  as  the  inguinal 
canal.  Such  a  swelling  is,  however,  uniformly  tense  and  elastic,  is 
dull  on  percussion,  and  generally  translucent,  whereas  an  irreducible, 
unstrangulated  intestinal  hernia  is  not  translucent,  is  of  more  lax 
consistence,  and  usually  gives  the  intestinal  note  on  percussion.  A 
strangulated  hernia  is  indeed  also  tense  like  a  hydrocele,  but  it  has 


Fig.  178. — Testicular  hydrocele. 


Fig.  179. — Bilateral  external  scrotal  inguinal  hernia. 


a  smaller  and  very  tender  pedicle,  and,  moreover,  is  always  attended  by 
symptoms  of  intestinal  obstruction.  But  the  following  case  will 
indicate  how  error  can  arise. 

A  young  man  sought  advice  for  a  classical  pear-shaped  irreducible 
testicular  hydrocele,  with  a  narrow  neck  in  the  inguinal  canal.  He 
stated  that  he  had  felt,  two  months  ago,  just  before  the  appearance  of 
the  hvdrocele,  a  sudden  pain  in  the  left  hypogastrium.  We  attached 
no  iniportance  to  this,  and  adhered  to  the  diagnosis.  At  the  operation, 
a  hydrocele  was  indeed  discovered,  but  it  had  a  narrow  offshoot  m 
the  inguinal  canal,  containing  a  small  adherent  plug  of  omentum. 
The  patient,  therefore,  had  a  small  strangulated  omental  hernia  in  a 
congenital  sac,  and  the  fluid  was  really  hernial   in  character.      The 


EXTERNAL    INGUINAL    HERNIA 


389 


pain  in  the  hypochondriuni  was  due  to  the  dragging  of  the  omentum 
at  the  moment  of  strangulation.  If  we  had  paid  more  regard  to  the 
history,  an  accurate  diagnosis  could  have  been  made. 

An  irreducible  granular  or  lobulated  scrotal  swelling  which 
possesses  a  pedicle  may  be  one  of  three  things  :  (i)  Omental  hernia; 
(2)  hernial  sac,  with  much  peri-hernial  fat ;  or  (3)  a  lipoma  of  the 
spermatic  cord.  Unaltered  omentum  in  a  hernial  sac  feels  more 
finely  granular  than  a  lipoma  of  the  spermatic  cord.  But  this  dis- 
tinction is  a  very  delicate  one,  and  can  only  be  appreciated  by  very 
experienced  fingers.  The  history  is  really  of  more  value  in  this 
connection.     If  the  patient  states  that  the  size  of  the  swelling  is  very 


Fig.  180. — Varicocele  with  atrophy  of  testicle. 


Fig.  181.  — Left-sided  hydrocele  and  external 
inguinal  hernia. 


variable,  we  should  think  of  hernia,  as  also  if  he  frequently  complains 
of  pain  during  digestion.  The  not  infrequent  cases  wherein  a  small 
lipoma  of  the  spermatic  cord  is  present  with  a  hernia  are  hardly 
capable  of  being  diagnosed. 

It  is  of  diagnostic  importance  to  know  that  mguinal  hernia  and 
lipoma  of  the  spermatic  cord  are  sometimes  accompanied  by  obstinate 
spermatic  cord  neuralgia,  the  cause  of  which  remains  obscure  until 
the  hernia  or  the  lipoma  appears. 

Diffuse  extension  of  peri-hernial  fat  is  rarely  found  in  external 
inguinal  herniae,  but  it  is  quite  general  in  internal  inguinal  herniae  and 
in  femoral  herniae. 


390 


SURGICAL    DISEASES    OF   THE   ABDOMINAL   AXD    PELVIC   VISCERA 


CHAPTER  LI. 
INTERNAL  OR  DIRECT  INGUINAL  HERNIA. 


There  is  usually  no  difficulty  in  distinguishing  an  internal  direct 
intjuinal  hernia  from  an  external  indirect  hernia,  if  one  bears  in  mind 
that  in  the  former  the  hernial  ring  leads  directly  into  the  abdominal 
cavity,  and  does  not  run  through  the  inguinal  canal.  This  form  is 
frequently  bilateral,  and  does  not  descend  into  the  testicle,  but  remains 
above  the  root  of  the  penis  after  giving  rise  to  a  pronounced  trans- 
verse fold  in  this  region 
(fig.  183).  In  contrast 
to  the  external  variety, 
internal  hernia  usually 
occurs  in  the  middle-aged 
and  the  old,  and  almost 
always  in  males.  On 
coughing  a  semi -glob- 
ular swelling  appears, 
which  is  more  sharply 
defined  laterally  than  in 
the  case  of  an  external 
inguinal  hernia. 

Xo  importance  should 
be  attached  to  the  clinical 
demonstration  of  the  po- 
sition of  the  deep  epi- 
gastric artery.  It  runs 
upward,  along  the  inner 
side  of  an  external  hernia, 
and  along  the  outer  side 
of  an  internal  hernia. 
\"aluable  as  this  sign  may 
be  at  the  operation,  when  a  case  is  doubtful,  it  is,  as  a  rule,  im- 
possible to  palpate  the   artery  before  operation. 

\i:t  In  addition  to  the  cases  which  fit  in  the  above  scheme,  there 
are  two  varieties  of  inguinal  hernia  which  may  present  some  diffi- 
culties in   diagnosis  : — 

(1)  External  inguinal  hernias  of  old  standing,  wherein  the  canal 
has  lost  its  obliquity,  and  the  hernial  ring  opens  directly  into  the 
abdominal  cavity  just  as  in  the  case  of  an  internal  hernia,  but 
the  hernial  sac  has  not  descended  into  the  scrotum.  The  gradual 
protrusion  of  the  swelling  towards  the  side  may,  in  these  circum- 
stances, be  the  onlv  sign  pointing  to  an  external  hernia. 

(2)  Internal  inguinal  herniae  which  descend  to  a  small  extent  into 
the  scrotum — a  condition  noted  by  Berger,  and  one  which  we  have 


Fig.  182. 


-Internal  inguinal  hernia  on  the  right,  and 
external  hernia  on  the  left. 


IXTERXAL    OR    DIRECT    IXGUIXAL    HERXIA 


)9I 


occasionally  observed — and  which  are  easily  mistaken  for  external 
herniae.  Difficulty  in  diagnosis  will  be  encountered  if  it  is  not  possible, 
on  examining  the  hernia  after  reduction,  in  a  recumbent  posture, 
with  one  finger  in  the  canal  and  the  other  introduced  directiv  into 
the  ring,  to  demonstrate  that  there  is  still  a  biidge  of  tissue  between 
the  two  fingers. 

The  question  which  arises  occasionally  in  connection  with  a 
direct  hernia,  as  to  whether  it  is  more  of  a  lipoma  or  more  of 
a  hernia,  is  unimportant,  because  it  is  quite  a  relative  matter.  All 
internal  inguinal  hernias  have  a  more  or  less  extensive  fatty  layer 
within  the  sac,  and  the  personal  equations  come  in  in  deciding  where 
;i  hernia  ceases  and  a  lipoma  begins. 

A  final  word  concerning  hernia  of  the  bladder.  This  mav 
occur  either  in  an  exter- 
nal or  an  internal  inguinal 
hernia,  but  more  frequent- 
ly in  the  latter.  It  will 
be  understood  that  one 
cannot  speak  of  hernia  of 
the  bladder,  when  a  piece 
of  this  organ  is  dragged 
up  into  the  ring  during 
the  course  of  a  radical 
operation  on  the  hernia. 
A  portion  of  the  bladder 
must  be  part  of  the  regular 
contents  of  the  hernia — • 
not  necessarily  of  the 
hernial  sac,  because  the 
bladder  often  extrudes 
itself,  extraperitoneally, 
along  the  side  of  the  sac, 
to  the  ring.  Disturbance 
of  micturition  would  jus- 
tify the  suspicion  of  a 
hernia  of  the  bladder, 
whether  it  be  difficulty  in 

emptying  the  organ,  or  frequent  tenesmus.  The  suspicion  would  be 
confirmed  if  it  were  observed  that  these  disturbances  coincided  with 
fulness  of  the  hernia.  It  is  possible  to  demonstrate  in  such  cases  that 
when  the  bladder  is  very  full  there  is  fluctuation  in  the  hernia  and 
dulness  over  it  on  percussion,  signs  which  disappear  after  the  bladder 
is  emptied.  In  some  circumstances  the  catheter  is  required  to  emptv 
the  bladder,  because  internal  inguinal  hernias  happen  to  be  most 
frequent  in  patients  wilh  enlarged  prostates. 


Fig.  i8j. — Bilateral  internal  inguinal  hernia. 


392      SURGICAL   DISEASES   OF   THE    ABDOMINAL   AND    PELVIC   VISCERA 


CHAPTER    LII, 


FEMORAL    HERNIA. 


There  are  not  many  swellings  which  can  be  mistaken  for  femoral 
liernia.  Errors  may,  however,  possibly  arise  in  connection  with 
hernial  protrusion  of  the  saphenous  vein,  enlarged  glands,  lipomata, 
burrowing  abscesses  in  the  crural  ring,  and,  finally,  inguinal  herniae. 
We  will  consider  these  in  order.  The  not  infrequent  protrusions 
of  the  saphenous  vein,  if  visible,  glimmer  with  a  blue  colour  through 
the  skin,  the  slightest  pressure  suffices  to  make  them  vanish,  but  they 

retui'n  as  soon  as  the  pres- 
sure is  relaxed.  They  react 
with  mathematical,  or  rather 
with  physiological,  precision 
to  every  variation  in  venous 
pressure,  such  as  is  caused 
bv  coughing,  vomiting,  &c., 
and  even  to  the  normal 
breathing,  in  a  recumbent 
position.  These  signs  are  so 
clear  that  confusion  would 
apparentlv  seem  impossible, 
but  as  a  matter  of  fact  errors 
have  arisen.  Burrowing 
abscesses  do  not,  as  a  rule, 
break  through  the  spaces 
transmittmg  the  vessels,  but 
more  laterally  through  a 
muscular  interspace ;  they 
are  frequently  multilocular, 
and  are  displaced  on  gradual 
pressure,  yielding  a  sen- 
sation of  elastic  resistance.  They  fill  up  again  as  soon  as  the 
pressure  is  relaxed,  without  any  abdominal  straining  or  change  in 
the  posture  of  the  patient.  But  even  in  the  cases  wherein  these 
abscesses  appear  towards  the  middle  line,  as  in  fig.  185,  the  other 
signs  are  so  definite,  that  an  error  is  hardly  possible  after  careful 
examination. 

Enlarged  glands  may  present  more  difficulties.  The  entrance  of 
the  infection  is  usually  found  somewhere  on  the  leg  or  foot.  The 
chief  characteristic  of  enlarged  glands,  even  when  chronic,  is  their 
sharp  limitation  at  the  femoral  ring,  whereas  a  hernia  always  possesses 


Fig.  184. — Bulging  of  the  femoral  region  through 
varicose  swelling  of  internal  saphenous  veiTi. 


FEMORAL    HERXIA 

a  pediclt  which  runs  under  Poupart's  hganient,  and  which  is  compres- 
sible against  the  pubic  bone.  The  rare  subserous  lipomata  are  also, 
strictly  speaking,  pedunculated,  but  the  pedicle  cannot  be  felt  like  the 
neck  of  a  hernia.  The  absence  of  a  palpable  process  into  the  abdo- 
men, combined  with  the  absence  of  any  variation  in  volume  and 
symptoms  of  hernial  protrusion,  would  suggest  a  lipoma,  behind  which 
there  may  be  a  small  pouch  of  peritoneum,  although  it  may  never  have 
contained  any  intestine  or  omentum.  It  is  very  significant  of  femoral 
hernias  that  a  verv  small  hernial  sac  is  often  surrounded  bv  a  large 
amount  of  fatty  tissue,  which  grows  into  a  lipomatoid  structure. 

Superficial  lipomata  also  occur  in  this  region,  either  as  isolated 
growths,  or  as  a  partial  manifestation  of  a  general  lipomatosis 
(fig.  iS8). 


G.  1S5. — Crural  burrowing  abscess  from  spinal  caries. 


Fig.  186. — Crural  hernia  in  female.      Its  relation  to 
Poupart's  ligament,  x — x. 


If  the  swelling  has  a  definite  pedicle  which  becomes  lost  under 
Poupart's  ligament,  the  diagnosis  of  hernia  can  hardly  be  mistaken. 
But  if  there  is  no  intestinal  note,  the  case  is  either  one  of  peri-hernial 
lipoma,  just  mentioned,  or  an  omental  hernia. 

The  differentiation  depends  less  upon  the  phvsical  condition  found 
on  palpation,  than  upon  the  presence  or  absence  of  svmptoms  of 
omental  dragging,  as  ah'eady  indicated  in  the  case  of  inguinal  hernia?. 
The  question,  is,  however,  one  of  indifi'erence,  because  if  treatment  is 
called  for,  operation  must  be  undertaken  in  either  case. 

If  a  pedunculated  swelling  feels  definitely  elastic,  there  must  be  a 
collection  of  fluid  in  an  old  obliterated  hernial  sac.     If  attacks  of  sudden 


394      SURGICAL    DISEASES    OF   THE   ABDO-AIIXAL    AND    PELVIC    VISCERA 

abdominal  pain,  without  intestinal  obstruction,  have  preceded  the 
onset  of  a  tense  hernial  swelling,  it  is  obvious  that  a  small  piece  of 
peritoneum  has  been  strangulated  in  the  ring  and  has  led  to  the 
development  of  hernial  fluid. 

Having  determined  that  the  swelling  is  a  hernia,  the  question  still 
remains  as  to  whether  it  is  really  a  femoral  hernia.  If  the  tumour  is 
clearlv  below  Poupart's  ligament,  the  matter  is  settled  ;  but  if  it  is 
riding  on  the  ligament  the  solution  is  not  so  clear.  It  may  be  an 
inouinal  hernia  which  has  wandered  downward,  or  it  mav  be  a  femoral 
hernia  which  has  grown  upwards  ffigs.  189  and  190).  The  differ- 
entiation is  not  difiicult,  if  we  are  able  to  reduce  the  hernia.  We  base 
our  decision  on  the  position    in   which   it  recedes,  and   by  feeling  the 


Fig.  187. — Femoral  hernia  in  a  male. 


Fig.  188 — .Symmetrical  lipomata  in  crural  regioi 


ring.  It  is,  however,  otherwise,  if  the  hernia  is  irreducible,  whether  it 
be  strangulated  or  not.  Incorrect  diagnoses  are  very  frequent  in  such 
cases,  and  as  a  rule  a  femoral  hernia  is  taken  to  be  an  inguinal  hernia. 
As  Poupart's  ligament  cannot  be  clearly  defined  because  it  is  overlain 
by  the  hernia,  and  because  it  is  obscured  by  fat  in  elderly  women, 
Malgaigne's  line  has  been  adopted  to  indicate  its  position,  i.e.,  the  line 
joining  the  spine  of  the  pubis  with  the  anterior  superior  spine  of  the 
ilium  (fig.  t86).  Everything  above  this  line  is  to  be  ascribed  to 
inguinal  hernia,  and  below  it,  to  femoral  hernia.  But  this  criterion  is 
not  always  reliable.     More  importance  is  to  be  attached  to  the  position 


FEMORAL   HERNIA 


395 


and  direction  of  the  neck  of  the  hernia,  which  can  generally  be  felt  on 
careful  palpation,  and  which  is  recognizable,  w-hen  strangulated,  by 
its  size  and  tenderness  on  pressure.  If  it  runs  vertically  and  is  capable 
of  being  moved  from  side  to  side  on  the  crest  of  the  pubes,  or  if  it 
appears  to  run  deeply  down  when  the  hernia  is  displaced  upwards,  the 
case  is  one  of  femoral  hernia.  If  it  runs  outwards  and  upwards,  or 
directly  outwards,  the  case  is  one  of  inguinal  hernia.  This  sign 
enables  a  definite  diagnosis  to  be  made  in  such  a  case  as  fig.  190, 
although  the  major  portion  of  the  hernial  swelling  was  above  Poupart's 
ligament. 

If  there  is  a  historv 
of  hernia,  but  we  find 
nothing  at  our  first  ex- 
amination, we  must  care- 
fully compare  the  two 
sides  for  slight  tissue 
thickening,  or  for  fine 
friction,  as  already  men- 
tioned in  connection  with 
inguinal  hernia.  We 
must  especially  observe 
w'hether  the  area  of  the 
fossa  ovalis  is  fuller  on 
one  side  than  on  the 
other.  In  this  wav  we 
may  sometimes  discover 
the  explanation  for  inex- 
plicable abdominal  pains, 
even  if  the  patient  denies 
any  hernial  protrusion. 
I  have  already  mentioned 
that  I  once  removed  an 
appendix  because  of  the 

history  and  the  diagnosis  of  the  family  practitioner,  and  then,  later 
on,  recognized  that  the  pains  which  continued  were  really  due  to  a 
small  concealed  femoral  hernia  on  the  right  side. 

There  are  a  few  abnonnalities  in  connection  with  femoral  hernia, 
which  are  generally  only  discovered  at  the  operation,  but  which  might 
be  recognized,  or  at  least  suspected,  on  careful  examination. 

For  instance,  the  hernial  sac  may  pierce  into  the  muscle  under 
the  fascia  of  the  pecf  incus,  and  thus  resemble  an  obturator  hernia — a  rare 
condition  only  occurring  in  women  and  designated  after  Cloquet.  The 
hernia  may  descend  under  the  large  vessels,  or  it  may  appear  to  their 
outer  side  in  the  opening  through  which  they  run,  or  it  mav  leave 
the   abdominal    cavity  through    a    muscular    interspace.     This   latter 

26 


Fig.  189. — Bilocular  femoral  hernia  encroaching  above 
Poupart's  ligament. 


39^      SURGICAL   DISEASES    OF   THE   ABDO.MIXAL   AND    PELVIC   VISCERA 

form,  the  so-called  Hesselbach's  hernia,  has  been  recognized  before 
operation  by  means  of  its  broad  base  and  its  lateral  position.  Finally, 
we  find  here,  as  in  inguinal  hernia,  a  pro-peritoneal  form,  which  does 
not  come  through  the  abdominal  wall. 


\ 


\ 


Fig.  190. —  Strangulated  femoral  hernia  projecting  above  Poupart's  ligament. 


CHAPTER    LIII. 
TRAUMATIC  HERNItE. 


The  surgeon  will  occasionally  be  confronted  with  the  question  as 
to  whether  the  hernia  which  he  has  demonstrated  has  arisen  through 
an  "accident."  The  terra  is  usually  meant  to  include  any  sudden 
strain,  which  does  not  come  within  the  patient's  ordinary  occupation, 
or  one  within  his  occupation,  if  it  has  overtaxed  his  strength.  Most 
of  these  cases  are  accounted  for  by  the  sudden  strain  of  abdominal 
pressure,  with  the  body  in  disadvantageous  posture. 

The  story  of  the  Zouave  trumpeter  is  typical  of  this.  As  he  was 
blowing  for  the  attack  at  Malakoff,  he  fell  into  a  hole,  and  got  up 
with  a  hernia. 

We  have  to  take  into  consideration  both  direct  and  indirect 
trauma.  Neither  form  can  cause  a  hernia  in  persons  hitherto  per- 
fectly normal.     But  indirect   trauma — rarely  direct — may   convert   a 


TRAUMATIC    HERNIA 


397 


tendency  to  hernia  into  actual  hernia,  i.e.,  the  stretching  of  the  pre- 
existing small  hernial  sac  and  the  consequent  dragging  of  the  parietal 
peritoneum  may  determine  the  entrance  of  some  intestine  or  omentum 
into  the  sac.  This  process  is,  as  a  rule,  so  painful,  that  it  prevents 
any  furlher  bodily  exertion,  and  the  patient  feels  bound  to  seek 
medical  advice.  These  two  conditions  are  usually  associated  in  the 
evidence  of  a  "  traumatic  hernia,"  though  there  are  exceptions 
varying  with  the  occupation  and  energy  of  the  workman. 

A  hernia  which  has  arisen  in  this  manner  is  small — at  most  the 
size  of  a  hen's  egg — the  sac  is  thin,  and  not  palpable  ;  the  hernial  ring 
is  generally  small  but  it  may  be  of  medium  size.  The  intestine  does 
not  always  protrude  when  the  patient  assumes  the  erect  posture,  but 
once  having  protruded  it  does  not  always  return  when  he  lies  down. 
The  hernia  is  only  slightly  movable,  without,  as  has  been  asserted, 
necessarily  being  strangulated.  There  should  be  no  traces  of  a 
truss  on  the  skin. 

The  consideration  of  these  circumstances  enables  us  to  decide 
whether  the  hernia  could  possibly  be  traumatic,  i.e.,  whether  it  could 
have  arisen  from  sudden  strain.  As  a  rule,  nothing  more  definite 
can  be  said,  unless  the  patient  happens  to  have  been  examined 
shortly  before,  specially  for  hernia.  However  reasonable  the  claim 
of  the  workman  for  compensation  may  be,  for  the  genuine  traumatic 
change  of  his  "  tendency  to  hernia  "  into  an  actual  hernia — for  in- 
stance, a  radical  cure  by  operation,  without  any  money  payment — 
nevertheless  the  practitioner  should  be  extremely  cautious  in  coun- 
tenancing the  fashion  of  making  a  profit  out  of  these  too  easily 
assumed  cases  of  traumatic  hernia. 

The  extent  to  which  these  attempts  may  go  is  illustrated  by  the 
fact  that  even  gonorrhoeal  epididymitis  and  inguinal  buboes  after 
soft  chancres  have  been  represented  as  "traumatic  hernia." 

Most  so-called  traumatic  hernias  are  of  the  external  variety  ;  but 
all  forms  have  been  at  times  ascribed  to  injury.  We  may,  however, 
discard  the  possibility,  in  internal  inguinal  hernije  and  umbilical 
hernise,  and  should  be  very  sceptical  with  femoral  herniae.  An 
epigastric  hernia  is  much  more  likely  to  be  due,  in  some  considerable 
degree,  to  trauma. 


398      SURGICAL   DISEASES   OF   THE   ABDOMINAL   AND   PELVIC   VISCERA 

CHAPTER    LIV. 
STRANGULATED  HERNIA. 

It  is  most  important  to  observe  that  strangulation  must  not  be 
confused  with  irredncibility,  for  it  is  only  one  special  variety  of 
irreducible  herniae.  Both  intestine  and  omentum  may  be  irreducible 
without  being  strangulated ;  the  cause  usually  is  the  presence  of 
adhesions.  Moreover,  the  omentum  within  the  sac  may  develop  so 
much,  entirely  of  its  own  accord,  that  it  is  unable  any  longer  to  slip 
back  through  the  hernial  ring,  even  if  no  adhesions  exist. 

A  special  form  of  irredncibility  is  found  in  connection  with  certain 
herni?e  of  the  caecum  and  ascending  colon,  and  also  of  the  sigmoid 
and  descending  colon.  In  these  cases,  not  only  does  the  intestine, 
which  is  covered  by  peritoneum,  leave  the  abdominal  cavity,  but  also 
its  extraperitoneal  site  of  attachment,  and,  in  consequence  of  the 
slipping  down  of  this  surface  of  attachment  into  the  area  of  the  hernia, 
the  intestine  loses  all  its  tendency  to  return  within  the  abdomen. 

It  may  be  mentioned  incidentally  that  it  is  obvious  that  the  hernia 
has  no  sac  on  this  surface. 

There  are  also  those  enormous  herniae  which  are  met  with  less 
frequently  than  formerly,  which,  apart  from  adhesions,  are  irreducible, 
because  the  abdomen  no  longer  contains  enough  space  to  receive  them. 
Petit  aptly  said  that  these  herniae  "  have  lost  their  right  of  domicile." 

The  subjective  sym.ptoms  of  a  non-strangulated  but  irreducible 
hernia  are  not,  as  a  rule,  any  more  severe  than  those  of  a  free  hernia. 
But  dragging  pains  are  often  present  ;  though  they  manifest  themselves 
in  the  upper  part  of  the  abdomen  rather  than  in  the  hernial  region. 
Local  pain  usually  arises  if  the  patient  maltreats  the  hernia  with  a 
truss. 

Strangulation  is  a  form  of  irredncibility  which  arises  suddenly, 
and  is  attended  by  constriction  of  the  pedicle,  fixity  of  the  presenting 
intestine,  with  disturbance  of  the  circulation  in  the  contents  of  the  sac. 
A  number  of  questions  require  answering  in  this  connection. 

(1)    Is  the  Case  really  one  of  Hernia? 

This  is  no  superfluous  question.  Every  surgeon  has  had  infants 
referred  to  him  with  the  diagnosis  of  strangulated  hernia,  when  the 
case  has  been  one  of  acutely  arising  hydrocele  in  an  infant.  The 
distinction  is  really  not  difficult.  The  tense  hydrocele  swelling  is,  as 
a  rule,  definitely  limited  above,  and  does  not  run  into  the  inguinal 
canal.     The  infant  passes    motions   and   flatus  and   does   not  vomit. 


STRANGULATED    HERNIA  399 

at  any  rate  persistently.  It  takes  the  breast  or  bottle,  again,  after  a 
short  interval,  an  indulgence  which  an  infant  with  a  strangulated 
hernia  never  enjoys.  It  certainly  cries,  because  the  rapidly  increas- 
ing effusion  is  a  source  of  discomfort,  but  it  does  not  appear  to 
suffer  severely.  If  one  has  made  certain  of  the  diagnosis,  by  careful 
examination,  the  swelling  may  be  tapped  quite  safely  and  the  anxious 
parents  be  convinced  of  the  accuracy  of  the  diagnosis. 

Besides  the  hydrocele  of  young  children,  there  are  complications 
connected  with  an  inguiual  testicle  which  may  resemble  strangulated 
hernia,  namely,  twisting  of  the  pedicle  oi  the  testicle  and  its  strangulation. 
This  error  is  all  the  more  accountable  because  most  inguinal  testicles 
are  associated  with  herniae,  and  the  patient  will  therefore  give  a  history 
of  hernia.  Formerly,  inflammation  and  strangulation  of  the  inguinal 
testicle  were  the  only  recognized  morbid  conditions  thereof,  but  since 
the  time  of  Nicoladoni  it  has  been  agreed  that  torsion  of  the  abnor- 
mally pediculated  testicle  is  the  usual  affection,  and  the  possibility  of 
strangulation  has  been  somewhat  neglected.  But  that  it  exists  appears 
from  the  following  case  : — 

A  patient  who  had  a  left-sided  hernia,  which,  however,  had  not  come 
out  of  the  inguinal  canal  since  his  fourteenth  year,  felt  a  severe  pain 
in  the  left  inguinal  region,  on  lifting  a  heavy  weight.  A  tender 
swelling,  which  looked  like  a  strangulated  hernia  at  first  sight, 
appeared.  But  the  emptiness  of  the  left  half  of  the  scrotum  and  the 
patency  of  the  intestine  enabled  a  correct  diagnosis  to  be  made,  and 
the  operation  showed  that  the  inguinal  testicle  had  slipped  down  to 
the  narrow  external  inguinal  ring  and  had  been  conducted  externally 
under  the  skin.  The  kinking  of  the  spermatic  vessels  at  the  external 
abdominal  ring,  and  their  dragging,  owing  to  the  abnormal  position 
of  the  testicle,  had  led  to  the  formation  of  a  considerable  infarct.  In 
this  case  the  diagnosis  could  only  lie  between  torsion  and  strangula- 
tion with  subcutaneous  displacement.  The  subcutaneous  position  of 
the  testicle  contra-indicated  simple  torsion.  If  a  testicle  within  the 
inguinal  canal  becomes  twisted,  it  remains  ^^'ithin  the  canal. 

The  symptoms  of  the  more  frequent  condition  of  torsion  are  as 
follow  :  sudden  severe  pain  and  the  appearance  of  a  tumour.  In 
addition,  there  are  often  reflex  symptoms  which  suggest  strangulated 
hernia,  viz.,  severe  abdominal  pains,  temporary  obstruction  to  the 
passage  of  motions  and  flatus,  and  even  collapse.  In  the  inguinal 
region,  there  will  be  found  a  tender  swelling,  like  a  strangulated  hernia. 
The  empty  scrotum  and  the  return  of  the  passage  of  motions  and 
flatus  after  the  cessation  of  the  original  reflex  symptoms,  usually 
enable  a  diagnosis  to  be  made.  But  as  it  is  impossible,  at  the  beginning, 
to  distinguish,  with  absolute  certainty,  between  a  twisted  testicle  in  the 
inguinal  canal  and  a  strangulated  interparietal  hernia,  and  as  surgical 
intervention  is  urgent  in  either  case,  it  is  bad  practice  to  wait  until  the 
diagnosis  is  established  by  signs  of  intestinal  gangrene  ;  but  treatment 


400      SURGICAL   DISEASES   OF   THE   ABDOMINAL   AND    PELVIC   VISCERA 

must  at  once  be  undertaken,  to  save  the  structure  which  is  in  trouble, 
whether  it  be  intestine  or  testicle. 

A  boy,  aged  i  year,  suddenly  developed  a  tense  swelling  about  the 
size  of  an  almond  in  the  right  inguinal  region,  and  therewith  had 
pain,  with  signs  of  general  malaise.  The  right  testicle  was  absent 
from  the  scrotum,  and  the  left  one  had  only  incompletely  descended. 
There  were  three  possibilities :  (i)  strangulated  hernia ;  (2)  acute 
hydrocele  in  the  inguinal  canal ;  and  (3)  torsion  of  a  testicle.  All 
these  three  circumstances  were  favoured  by  the  presence  of  an 
inguinal  testicle.  The  absence  of  persistent  vomiting,  the  softness 
of  the  abdomen,  and  especially  the  passage  of  motions,  were  points 
against  a  strangulated  hernia.  Flatus  was  retained,  but  nothing 
definite  could  be  inferred  from  this.  The  marked  disturbance  of 
the  general  condition  showed  that  it  could  not  be  a  mere  hydrocele. 
Torsion  of  the  testicle  remained,  therefore,  as  the  most  probable 
diagnosis,  and  this  was  confirmed  by  the  operation,  which  was  per- 
formed forthwith.  The  little  patient  repeated  the  whole  procedure, 
a  year  later,  on  the  other  side. 

The  same  considerations  should  guide  us  in  the  case  of  torsion 
of  a  testicle,  which  is  in  the  scrotiun.  There  is,  of  course,  no 
emptiness  of  the  scrotum,  as  a  diagnostic  sign  in  such  a  case. 

There  are  some  circumstances  in  which  we  may  hesitate  as  to  the 
diagnosis  between  a  strangulated  hernia  and  a  mass  of  swollen  glands- 
If  there  are  any  intestinal  symptoms  there  cannot  be  any  possible 
doubt,  and  it  is  incredible  that  any  practitioner  should  order  poultices 
to  what  is  really  a  strangulated  femoral  hernia,  in  order  to  "  ripen  " 
the  swelling.  The  following  case  will,  however,  show  that  both 
patient  and  practitioner  may  succumb  to  a  series  of  misleading 
circumstances. 

A  female,  aged  50,  became  ill  with  acute  cholecystitis,  and  suffered 
from  very  painful  swelling  of  the  gall-bladder.  The  initial  vomiting 
ceased  and  the  cholecystitis  subsided  somewhat.  But  at  the  same 
time  the  doctor  accidentally  discovered  a  tender  swelling  in  the  left 
groin.  No  definite  pedicle  could  be  distinguished.  As  there  was 
neither  vomiting  nor  colic,  and  as  the  abdomen  was  soft,  and  as  there 
was  an  erosion  on  the  corresponding  lip  of  the  vulva,  which  suggested 
a  glandular  swelling,  the  patient  was  watched  for  a  day.  The  absence 
of  the  passage  of  flatus  determined  the  diagnosis  of  strangulated 
hernia  after  the  lapse  of  this  time — but  it  was  too  late.  The  patient 
died  suddenly  during  the  preparations  for  operation.  The  autopsy 
showed  not  only  a  severe  suppurative  cholecystitis  but  also  a  strangu- 
lated hernia,  with  gangrene  at  the  constricting  ring.  The  strangulation 
evidently  took  place  during  the  cholecystitis  as  a  result  of  the  vomit- 
ing, but  the  patient  was  not  intelligent  enough  to  notice  it.  There 
was  no  vomiting  or  colic  because  the  patient  was  under  dietetic 
treatment  owing  to  the  cholecystitis,  and  therefore  the  intestine  was 
almost  empty,  The  erosion  on  the  vulva  also  contributed  its  share 
towards  the  error. 


STRANGULATED    HERNIA  4OI 

(2)  Is  the  Hernia  Strangulated? 

One  of  the  most  important  pieces  of  evidence  for  strangulation 
is  afforded  by  the  pain  on  pressure  over  the  site  of  the  constriction, 
usually  at  the  hernial  ring.  The  obstruction  of  the  bowel,  and  the 
symptoms  consequent  thereon,  constitute  further  evidence.  This 
obstruction  also  occasionally  occurs  in  Littre's  hernia,  which  involves 
only  the  intestinal  wall.  Strangulation  of  omentum  is  distinguished 
from  ordinary  irreducibility  thereof  by  the  sudden  onset  of  symptoms, 
the  pain  on  pressure  over  the  site  of  strangulation,  and  the  tension 
of  the  hernia  owing  to  the  development  of  hernial  fluid. 

We  have  mentioned  an  example  of  such  strangulation  of  omentum 
in  the  chapter  on  Inguinal  Hernise. 

There  is  one  further  possibility  in  connection  with  strangulated 
hernia.  Formerly  one  heard  much  about  inflauiination  of  a  hernia, 
and  strangulation  was  regarded  as  inflammation.  There  is  nothing 
surprising  in  the  fact  that  the  sac  of  a  strangulated  hernia  may 
inflame  after  a  time,  in  consequence  of  infection  by  organisms  which 
wander  through  from  the  bowel.  The  inflammation  is,  however, 
secondary  in  such  circumstances.  Primary  inflammation  of  a  hernia 
is,  on  the  other  hand,  not  frequent.  The  following  conditions  are 
most  important  : — 

(a)  Appendicitis  in  a  Hernial  Sac. — The  appendix  is  not  infrequently 
found  in  right-sided  herniae ;  it  has  even  been  found  on  the  left  side 
and  also  in  umbilical  herni?e.  It  may  become  inflamed  within 
the  hernial  sac  and  perforate  there.  Such  a  case  is  usually  mistaken 
for  a  strangulated  hernia,  until  the  error  is  rectified  at  the  operation. 
But  the  sequence  of  symptoms  ought  to  give  a  correct  clue.  In  a 
strangulated  hernia  the  first  symptoms  are  those  of  intestinal  obstruc- 
tion, and  then,  after  they  have  persisted  for  some  time,  comes  the 
inflammation— the  hernial  phlegmon.  But  if  appendicitis  starts  in 
a  hernial  sac,  the  inflammatory  symptoms  come  first,  and  there 
is  pyrexia.  Should  intestinal  obstruction  eventually  supervene,  it  is 
a  much  later  phenomenon.  In  most  cases  of  strangulated  hernia 
the  pain  on  pressure  is  especially  marked  over  the  hernial  ring ;  in 
appendicitis,  however,  it  is  from  the  first  in  the  hernia  itself. 

{b)  The  involvement  of  the  hernial  sac  in  a  General  Peritonitis. — 
The  differential  diagnosis  depends  upon  those  considerations  which 
were  advanced  in  distinguishing  between  peritonitis  and  intestinal 
obstruction.  The  same  applies  to  a  hernia  involved  in  the  sequelai 
of  an  acnte  pancreatitis.  In  both  cases  the  severity  of  the  abdominal 
symptoms  will  be  very  striking,  considering  the  short  duration 
of  the  supposed  strangulation. 

(c)  Tubercle  of  the  Hernial  Sac. — This  is  usually  a  consequence  of 
general  tubercular  peritonitis.  But  it  sometimes  happens  that  this 
latter  causes  no  symptoms,  and  the  practitioner  is  only  consulted 
about  the  disease  of  the  hernial  sac.  Whereas  a  miliary  tuberculosis 
of  the  hernial  sac  with  fluid  contents  is  most  likely  to  be  taken  for  a 


402      SURGICAL    DISEASES   OF   THE   ABDOMINAL   AND   PELVIC   VISCERA 

hydrocele,  the  nodular  form  is  easily  confused  with  a  strangulated, 
or  at  least  with  an  irreducible,  mass  of  omentum.  If,  however,  one 
bears  in  mind  the  possibility  of  tubercle  of  the  hernial  sac,  suspicion 
thereof  will  be  aroused  by  the  presence  of  isolated  nodules,  by  the 
pain  on  pressure,  and  by  the  great  hardness  of  the  swelling.  A 
careful  examination  of  the  abdomen  may  perhaps  find  support  for 
the  diagnosis.  Abdominal  pains  are  of  less  diagnostic  significance, 
because,  although  they  are  frequent  in  tubercular  peritonitis,  they  may 
also  be  caused  by  strangulated  omentum. 

(d)  Sutter  and  others  have  shown  that  metastatic  inflammation 
of  an  empty  hernial  sac  may  resemble  the  clinical  symptoms  of 
strangulation. 

There  are  three  possible  events  which  may  introduce  error  into  the 
solution  of  the  last  two  problems,  with  which  we  have  been  dealing  ; 
first,  the  combination  of  external  hernia  witli  internal  intestinal 
obstruction.  Let  us  assume  the  case  of  a  patient  with  all  the  signs  of 
intestinal  obstruction,  in  whom  we  also  find  an  irreducible  hernia^ 
and  we  are  inclined  to  ascribe  to  it  the  cause  of  the  obstruction.  If  the 
hernial  swelling  is  soft  and  not  painful  on  pressure,  the  cause  of  the 
obstruction  must  be  elsewhere  ;  either  in  another  hernia,  which  has 
been  overlooked,  or  in  some  disease  within  the  abdomen  itself. 

On  the  other  hand,  there  are  cases  wherein  we  find  no  hernia,  and 
are  therefore  inclined  to  attribute  the  intestinal  obstruction  to  some 
internal  cause.  On  inquiry  we  may  learn  that  the  patient  has  put 
back  a  hernia.  Careful  examination  of  the  site  occupied  by  the 
hernia  may  then  show  some  slight  retraction,  and  we  may  discover 
in  the  abdomen,  behind  the  ring,  an  indefinite  resistance,  which  is 
painful  on  pressure.  Our  diagnosis  must  then  be  that  of  reduction  en 
masse.  These  cases  are,  however,  becoming  rarer,  as  fortunately 
violent  taxis  is  giving  way  to  herniotomy. 

It  occasionally  happens  that  an  omental  hernia  becomes  painful 
on  pressure.  Symptoms  occur,  at  the  same  time,  suggestive  either  of 
peritonitis  or  of  intestinal  obstruction.  There  may  be  found  in  the 
abdomen  a  tumour-like  painful  area  of  resistance  with  corresponding 
dulness,  or  even,  under  some  circumstances,  a  free  fluid  effusion.  If 
these  symptoms  occur  on  the  right  side,  in  a  patient  who  has  already 
suffered  from  attacks  of  pain  in  this  region,  the  diagnosis  usually 
made  is  that  of  appendicitis  with  extension  of  the  inflammation  into 
.the  sac.  This  diagnosis  seems  all  the  more  likely  as  the  process  is 
often  accompanied  by  moderate  fever.  Operation,  however,  shows 
that  the  case  is  one  of  torsion  of  a  large  mass  of  omentum,  the  extremity 
of  which  is  firmly  fixed  in  the  hernial  sac— a  condition  with  which 
all  surgeons  are  familiar,  but  which  has  been  specially  described  by 
Hochenegg. 

(3)  What  does  the  Hernia  Contain? 

If  signs  of  intestinal  obstruction  are  present,  we  must  assume  that 
the  hernia  is  intestinal ;  if  they  are  not  present  the  hernia  must  be 
omental.     One  must  be  very  cautious  in  drawing  any  conclusion  from 


STRAXGULATED    HERNIA 


403 


physical  examination.  A  tympanitic  note  of  course  indicates  an 
intestinal  hernia.  A  dull  note  is  of  no  significance,  as  small  intestinal 
herniae  are  very  liable  to  yield  complete  dulness  on  percussion.  The 
feel  of  the  hernia  can  never  be  relied  on.  The  granular  consistence 
of  omentum  may  be  concealed  by  hernial  fluid,  and,  on  the  other 
hand,  a  small  coil  of  intestine  is  often  found  strangulated  in  cases 
wherein  an  omental  mass  can  be  definitely  demonstrated.  If  there  is  a 
small  movable  body  in  the  hernial  sac  of  a  female,  the  case  is  one  of  a 
sirangiilated  ovary,  a  condition  which  is  not  rare,  even  in  young  girls. 

(4)  Where  is  the  Strangulation  Situated? 

The  strangulation  may  be  in  the  neck  of  the  sac,  at  the  hernial 
ring,  or  in  the  sac  itself. 

The  strangulation  is  especially  at  the  neck  of  the  sac  in  inguinal 
herniae,  which  usually  present  a  ring-shaped  thickenmg  at  the  level 
of  the  internal  ring.  As  this  ring  may  shift  as  far  as  the  peripheral 
end  of  the  sac,  in  consequence  of  the  constant  onward  movement  of 
the  peritoneum,  the  strangulation  may  occasionally  occur  quite  close 
to  the  head  of  the  sac.  We  may  assume  the  presence  of  this  con- 
dition, if  the  central  portion  of  the  hernial  swelling  is  soft  and 
painless,  while  the  peripheral  portion  is  tense,  and  tender  to  pressure. 
As  a  rule,  a  strangulation  within  the  sac  is  at  the  level  of  the  internal 
inguinal  ring,  and  one  may  assert  that  most  strangulations  at  this 
spot  are  strangulations  within  the  hernial  sac,  because  the  internal 
ring  is  not  itself  tight  enough  to  cause  a  strangulation.  If  the 
diagnosis  is  at  all  possible,  it  will  depend  upon  the  localization  of  the 
greatest  amount  of  pain  on  pressure.  Strangulation  at  the  external 
ring  is  recognized  in  a  similar  manner,  but  here  the  strangulation 
is  not  caused  so  much  by  sac  as  by  the  fibrous  elements  of  the 
inguinal  ring. 

In  cases  of  femoral  hernia,  the  strangulation  usually  takes  place  at 
the  femoral  ring;  in  uinhilical  hernia,  it  is  due  to  constriction  at  the 
umbilical  ring,  but  it  may  occur  in  one  of  the  frequent  pouches  of 
the  hernial  sac.  In  the  latter  case,  only  one  segment  of  the  hernial 
swelling  will  be  tense  and  painful  on  pressure. 

Finall}^,  there  are  cases  wherein  the  intestine  is  caught  by  a  noose- 
like band  of  connective  tissue  arising  from  the  hernial  sac.  Such  a 
condition  is  first  recognized  at  the  operation. 

(5)  What  is  the  Condition  of  the  Strangulated  Gut? 

The  duration  of  the  strangulation  affords  important  information, 
because  the  intestine  usually  retains  its  vitality  for  the  first  twenty-four 
hours,  though    the    constricting   furrow  may    become    necrotic  after 


404      SURGICAL   DISEASES   OF   THE    ABDOMINAL   AND    PELVIC   VISCERA 

twelve  hours.  If,  however,  the  constriction  is  not  very  tight,  the 
intestine  may  recover  itself,  even  after  several  days'  strangulation. 
All  depends  upon  the  degree  of  circulatory  disturbance,  which  is 
usually  greater  in  small  hernise  than  in  large  ones.  Gangrene  is 
therefore  more  probable  in  a  small  hernial  swelling  than  when  a  large 
mass  of  intestine  and  omentum  is  present.  The  presence  of  omentum 
in  the  hernia  permits  us  to  make  a  more  favourable  prognosis  in 
regard  to  the  intestine,  because  the  omentum  serves  as  a  protecting 
pillow  to  it  in  the  hernial  ring.  As  long  as  the  hernial  swelling 
remains  movable  and  the  skin  above  it  can  be  picked  up,  and  is 
neither  red  nor  oedematous,  so  long  is  the  recovery  of  the  intestine 
not  impossible.  But  if  inflammatory  symptoms  have  occurred  in  any 
degree,  from  simple  oedema  of  the  integument  to  a  definite  hernial 
phlegmon,  we  must  expect  that  the  intestine  has  been  severely 
damaged. 

Although  the  indications  are  for  immediate  operation  in  all  cases, 
nevertheless  if  circumstances  prevent  it  being  carried  out  forthwith,  we 
may  venture  upon  a  modest  attempt  at  taxis,  if  the  strangulation  is 
recent  and  inflammatory  symptoms  are  absent.  But  if  the  operation 
can  be  done  at  once — and  this  is  always  the  case  nowadays,  except 
in  remote  districts — one  may  quite  conscientiously  abandon  taxis. 
Infants,  however,  provide  an  exception.  Strangulated  hernia  is  very 
rare  during  the  first  year  of  life ;  at  this  period  hernise  are  easily 
reducible  and  never  cause  gangrene.  As  a  rule,  the  hernia  goes  back 
when  the  child  is  put  in  a  bath. 

(6)  The  Questions  which  may  Arise  during  the   Operation. 

We  shall  not  waste  any  words  over  the  recognition  of  the  various 
layers  of  the  hernial  coverings — a  hobby-horse  of  the  older  surgeons. 
The  layers  may  represent  the  usual  coverings  in  recent  herniae, 
but  in  old  hernias  they  may  be  considerably  increased  in  number  by 
the  growth  of  new  layers  of  connective  tissue.  The  careful  operator 
will  succeed  in  entering  the  hernial  sac,  tiiio  if  not  cito,  even  with- 
out counting  the  layers  ;  but  he  must  remember  that  not  every 
space  containing  fluid  is  the  hernial  sac.  Cystic  spaces  containing 
serous  fluid  often  occur  around  the  hernial  sac,  especially  in  femoral 
hernia,  and  if  the  hernia  is  strangulated  the  serous  fluid  may  be  mixed 
with  blood. 

The  decision  made  from  the  appearance  of  the  intestine  is  of  greater 
importance  ;  and  it  is  necessary  to  consider  not  only  the  strangulated 
coil  but  also  the  bowel  leading  towards  it.  In  order  to  pull  it  suffi- 
ciently forward  it  is  necessary  to  widen  the  constriction  previously, 
but  care  must  be  taken  lest  the  hernial  coil  slips  back  into  the 
abdomen  unexpectedly  and  unperceived.  If  the  intestine  is  smooth 
and  shiny,  and  if  definite   contractibility  is   present  in   the  whole   of 


STRANGULATED    HERNIA  405 

the  strangulated  coil,  including  the  constricted  ring,  we  may  safely 
reduce  it,  even  though  it  may  have  seemed  congested  at  first  and 
felt  somewhat  thick.  The  bluish  discoloration  improves  as  we 
wait,  and  the  thickening  is  preferable  to  the  opposite  condition.  The 
intestine  may  be  suspected  if  the  contractions  only  start  after  long 
waiting,  and  are  then  very  indolent.  In  such  doubtful  cases  the 
circulation  in  the  mesentery  must  be  observed,  and  special  attention 
must  be  paid  to  the  arteries  to  note  whether  they  are  pulsating,  and 
to  the  veins,  to  see  whether  they  are  thrombosed.  Intestine  should 
not  be  replaced  if  it  cannot  be  excited  to  contract  in  every  part, 
including  even  the  constricted  ring.  Even  if  its  consistence  remains 
normal,  or  only  slightly  thickened,  it  should  not  be  replaced.  It  is 
quite  certain  that  if  necrosis  has  once  started  it  will  become  com- 
plete, in  cases  wherein  the  intestinal  wall  is  disposed  in  small  folds 
and  its  consistence  is  diminished,  whether  its  colour  be  black,  green, 
or  grey.  The  character  of  the  hernial  fluid  may  prove  of  value  in 
doubtful  cases.  A  clear,  odourless  fluid  indicates  that  the  intestine 
is  capable  of  recovery  ;  a  turbid  offensive  fluid  shows  that  necrosis 
has  begun.  Obviously,  we  must  not  allow  an  apparently  healthy 
hernial  fluid  to  reassure  us,  if,  for  instance,  we  find  clear  signs  of 
necrosis  at  a  constricting  ring.  On  the  other  hand,  the  fluid  may  be 
somewhat  offensive  or  slii^htlv  turbid  in  cases  wherein  the  bowel  is 
capable  of  recovery. 

I  was  once  called  to  a  distant  village  to  see  an  old  woman  with 
a  strangulated  femoral  hernia.  When  I  arrived  the  practitioner 
informed  me  that  the  symptoms  of  obstruction  had  subsided,  but 
that  the  hernial  swelling  was  increasing.  The  swelling  felt  very 
tense,  and  when  it  was  opened  a  little  offensive  gas  escaped.  This 
led  into  the  femoral  hernial  sac,  which  contained  a  very  few  drops 
of  pus,  and  which  was  separated  from  the  abdominal  cavity  by 
obviously  recent  adhesions.  Recovery  followed  in  a  short  time  with- 
out further  intestinal  disturbances.  The  intestine  which  had  been 
strangulated  had  returned  of  its  own  accord,  leaving  behind  some 
bacteria,  which  did  nothing  more  but  infect  the  hernial  sac.  This 
case  reminds  us  of  the  observations  which  we  have  already  made 
in  regard  to  inflammation  of  an  empty  hernial  sac. 

(7)   Questions    which    Arise    after    Reduction    by    the    Open    or 

Bloodless    Method. 

A  coil  of  intestine  which  has  been  strangulated  for  some  hours 
does  not  always  resume  its  functional  activity  forthwith.  We  must, 
therefore,  not  be  surprised  if  some  colic  still  'persists  for  several 
hours,  or  for  a  day  or  two  after  the  strangulation  has  been  relieved. 
It  may  not  be  easy  to  obtain  the  passage  of  motions  and  flatus  even 
after  copious  enemata.     If  reduction  has  been   effected  by  taxis   we 


406      SURGICAL   DISEASES   OF   THE    ABDOMINAL   AND    PELVIC   VISCERA 

must  not  allow  this  fact  to  reassure  us  very  easily,  but  should  think 
of  the  possibility  of  a  reduction  en  masse.  An  operation  must  be 
resorted  to  if  the  symptoms  continue  for  several  hours  with  the  same 
severity.  If  herniotomy  has  been  performed  we  may  wait  longer, 
but  must  undertake  laparotomy  if  the  symptoms  increase  instead  of 
abating,  especially  if  the  pulse  becomes  unsatisfactory.  There  may 
be  some  additional  intra-abdominal  trouble,  such  as  a  volvulus,  or 
kinking,  owing  to  adhesions.  The  acceleration  of  the  pulse  should 
suggest  to  us  that  we  have  probably  erred  in  deciding  that  the 
intestinal  coil  retained  its  vitality. 

I  have  seen  gangrene  come  on  in  an  entire  coil  after  a  skilfully 
performed  herniotomy  in  a  case  wherein  the  strangulation  had  not 
existed  for  twelve  hours. 

There  are  some  cases  in  which  everything  goes  well  at  first,  but 
wherein  the  patient  begins  to  complain  again,  after  the  lapse  of 
several  weeks,  of  attacks  of  colic,  and,  finally,  of  retentions  of  motions 
and  flatus — in  a  word,  of  the  symptoms  of  chronic  intestinal  obstruc- 
tion. If  we  operate  we  find  that  a  ring-shaped  or  a  channel-shaped 
narrow^ing  exists  in  the  place  of  the  strangulated  coil,  or  that  the 
whole  coil  has  been  caked  into  an  inextricable  ball  through  adhe- 
sions. Both  these  conditions  show  that  we  were  too  optimistic  in 
our  opinion  of  the  intestine  at  the  time  of  operation.  They  both 
indicate  that  the  mucous  membrane  has  sloughed  more  or  less  exten- 
sively, and  this  may  occur  even  when  the  serous  surface  appeared  to 
be  capable  of  living  and  has,  as  a  matter  of  fact,  retained  its  vitality. 
The  only  early  warning  of  the  onset  of  this  late  stenosis  is  offered 
by  intestinal  haemorrhage  and  persistent  diarrhoea  coming  on  in  the 
first  weeks  after  the  reduction. 

A  female,  aged  60,  was  operated  on  for  strangulation  of  an 
umbilical  hernia,  which  had  persisted  for  eighteen  hours.  The  intes- 
tine appeared  to  be  healthy  and  was  replaced.  The  intestinal  func- 
tions were  normal  for  the  first  few  days,  but  classical  symptoms 
of  chronic  intestinal  obstruction  occurred  after  the  second  or  third 
week.  They  increased  so  much  that  another  operation  became 
necessary  in  the  seventh  week.  The  intestine  which  had  been 
strangulated  had  developed  into  an  S-shaped  mass,  with  very  firm 
adhesions  of  one  portion  of  the  coil.  An  entero-anastamosis  was 
performed,  with  complete  and  permanent  recovery. 


DIFFICULTIES    OF   DEFALCATION  407 

CHAPTER   LV. 
DIFFICULTIES  OF  DEFECATION. 

In  the  popular  sense  this  term  includes  several  conditions  of 
varied  significance  which  the  practitioner  must  separate  from  one 
another.  They  comprise  functional  derangements  of  the  whole 
intestine,  or,  at  least,  of  the  large  intestine,  and  also  disorders  which 
are  due  to  some  local  affection  of  the  rectum  or  its  vicinity.  We 
have  discussed  the  former  in  the  section  on  '' intestmal  obstruction." 

The  following  are  the  symptoms  by  which  rectal  disease  manifests 
itself  :— 

(i)  Simple  Constipation,  i.e.,  Difficnlty  in  evacuating  the  Feeces,  but 
no  Pain  or  Tenesmus. — This  form  of  constipation  is  rare.  It  occurs 
in  simple  weakness  of  the  rectal  muscle  (proctogenic  constipation), 
with  tumours  of  the  true  pelvis,  which  mechanically  compress  the 
rectum  from  without,  and  a  fair  amount  of  compression  is  required 
before  defjecation  is  compromised.  Retroflexion  of  the  gravid  or 
myomatous  uterus,  exudations  within  the  true  pelvis,  cysts,  and 
solid  tumours  may  be  mentioned  as  examples.  The  notorious 
"tape-like"  faeces  are  sometimes  found  in  these  circumstances. 

We  have  been  told  by  a  patient  with  a  dermoid  in  the  pelvis  that 
his  motions  were  as  thin  as  cardboard. 

(2)  Coustipatiou  associated  witti  Constant  Tenesmus. — The  evacua- 
tions are  soft  and  pulp)^,  or  even  quite  liquid,  and  are  frequently 
expelled  in  very  small  quantities  at  a  time.  The  patient  experiences 
an  incessant  desire  to  go  to  stool.  This  picture  is  most  frequently 
encountered  in  cases  of  progressive  pressure  on  the  rectum  from  with- 
out by  one  of  the  swellings  just  mentioned. 

(3)  Tenesmus,  without  Constipation,  but  until  the  Passage  of  Blood, 
Mucus  or  Sero-sanions  Fluid,  during  the  Acts  of  Defcecation,  and  in  their 
intervals.  —  If  a  patient  complains  of  these  symptoms,  and  especially 
if  his  clean  shirt  is  soiled  with  red  or  pinkish  stains,  we  may  at  once 
assume  that  some  ulcerative  process  is  present,  which  does  not  lead 
to  stenosis.  It  may  be  associated  with  an  ulcerative  colitis,  extending 
low  down,  an  innocent  polypus,  a  syphilitic  or  tubercular  lesion, 
or  it  may  be  due  to  cancer  which  has  not  yet  reached  the  stage  of 
stenosis — the  most  frequent  cause. 

(4)  Tenesmus  with  Constipation,  Passage  of  Liquid,  Pulpy  or  softly 
formed  Feeces  in  small  Quantities,  accompanied  by  Blood  or  Scro-sanious 
Fluid. — This  assemblage  of  symptoms  points  to  an  ulcerative  lesion, 
which  is  also  causing  stenosis,  i.e.,  to  cancerous,  syphilitic,  or 
gonorrhoea!  stricture. 


408      SURGICAL   DISEASES    OF   THE   ABDOMINAL   AND    PELVIC   VISCERA 

The  history  affords  certain  indications;  thus  in  childhood  polypus 
is  the  most  frequent  cause  ;  in  females  from  adolescence  to  middle 
age  syphilis  or  gonorrhoea  is,  under  certain  conditions,  the  most 
probable  cause ;  in  elderly  people  a  villous  polypus,  or  cancer,  is 
most  likely  to  be  present.  Exammation  of  the  rectum  must  never  be 
omitted.  The  trouble  must  never  be  attributed  to  piles,  which  may 
accidentally  be  present,  and  they  should  never  serve  as  an  excuse  for 
an  incomplete  examination.  That  so  many  advanced  cases  of  cancer 
are  sent  for  operation  with  the  mistaken  diagnosis  of  rectal  catarrh  or 
haemorrhoids  is  due  to  the  shyness  of  the  patients — and  often  of 
practitioners — in  the  matter  of  rectal  examination.  It  is  quite  in- 
telligible and  praiseworthy  that  the  practitioner  who  is  engaged  in 
surgery  or  in  obstetrics  should  avoid  contaminating  his  fingers 
unnecessarily;  but  nowadays  a  finger-stall  removes  the  risk  of  con- 
tamination, and  a  rectal  examination  in  this  type  of  case  is  never 
"  unnecessary." 

If  we  feel  a  soft  movable  structure,  with  a  more  or  less  long  stalk, 
which  easily  escapes  the  finger,  the  case  is  one  of  polypus — a  mucous 
polypus  in  children,  a  mucous  polypus  or  a  villous  polypus  in  adults. 
If  the  mucous  membrane  appears  to  be  softly  granular  over  a  diffuse 
area,  or  if  it  be  studded  with  superficial  ulcers,  which  are  most 
distinctly  recognizable  with  a  rectal  speculum,  the  condition  represents 
an  early  stage  of  chronic  gonorrhoeal  or  syphilitic  proctitis. 

Flat,  very  painful  ulcers  in  the  vicinity  of  the  anus  suggest 
tubercle.  We  have  already  discussed  the  differential  diagnosis 
between  this  condition  and  non-specific  ulcerative  colitis. 

If  the  finger  defines  a  shell-like  elevation  of  the  mucous  membrane 
with  an  overhanging,  more  or  less  firm  border,  and  a  friable,  easily 
bleeding  surface,  the  case  is  one  of  cancer,  which  has  not  yet 
encircled  the  bowel.  If  there  be  any  doubt,  such  as  might  arise  in 
the  presence  of  a  fiat  non-pedunculated  papilloma,  a  histological 
examination  must  be  made.  Such  papillomata  often  become  malig- 
nant. The  same  applies  to  the  polypoid  condition  of  the  rectum, 
in  which  the  whole  rectum,  and  often  a  considerable  portion  of  the 
large  intestine,  is  invaded  by  numerous  polypi.  If  the  finger  enters 
into  a  smooth-walled,  rigid,  cylindrical  tube,  the  case  is  one  of 
stricture,  following  gonorrhoeal  or  syphilitic  proctitis.  If,  on  the 
other  hand,  we  feel  a  circular  wall,  into  whose  centre  the  finger 
can  scarcely  impinge,  owing  to  the  narrowness  of  the  opening,  and 
if  the  friable  tissue  breaks  down,  there  can  be  no  question  that  we 
are  dealing  with  a  ring-shaped  carcinoma.  If  the  growth  is  high 
up,  we  must  direct  the  patient  to  bear  down,  or  we  must  press  the 
abdomen  downwards  with  our  free  hand.  According  to  Hochenegg, 
a  remarkably  wide  ampulla  should  raise  the  suspicion  of   a  cancer, 


DIFFICULTIES   OF    DEFECATION  409 

situated  high  up,  and  fixing  the  pelvic  colon.  If  a  cancer  of  the  lower 
segment  of  the  rectum  protrudes  through  the  anus,  the  diagnosis  is 
easy  enough  (fig.  194).     Sarcoma  is  much  more  rare   in  this  region 

(fig-  196). 

(5)   Painful  Defctcation. — We  meet  with   this  symptom  in  various 

conditions  : — 

{a)  If  a  patient  tells  us  that  he  suffers  from  severe  cutting  pain 
in  the  anus  after  every  action  of  the  bow^els,  that  the  pain  starts 
immediately,  and  lasts  for  about  fifteen  minutes  or  longer,  and  that 
he  postpones  defaecation  as  long  as  possible  on  account  of  the  pain, 
we  may  conclude  that  he  is  suffering  from  a  fissure.  On  examining 
the  anal  aperture,  we  see  one  or  more  radiating  cracks  which,  if  care- 
fully separated  from  each  other,  look  like  defects  in  superficial  epi- 
dermis, wdth  a  reddened  base.  Sometimes  they  are  situated  between 
small  nodules  of  haemorrhoids  of  a  perfectly  unirritating  character. 

[b)  If,  on  the  other  hand,  the  pain  is  only  occasional,  and  comes 
on  in  attacks  lasting  for  a  few  days,  the  pain  at  first  being  confined  to 
the  moment  of  defaecation,  but  subsequently  becoming  more  per- 
sistent, only  to  disappear  for  some  time,  after  the  loss  of  considerable 
dark  blood,  we  may  be  certain  that  the  condition  is  one  of  inflam- 
matory changes  in  haemorrhoids,  i.e.,  thrombosis  in  their  venous 
spaces.  One  of  my  patients  compared  the  severity  of  the  pain  to 
toothache.  Sometimes  the  loss  of  blood  only  occurs  periodically  at 
long  intervals  ;  at  other  times  the  loss  of  blood  may  be  constant  at 
each  action  of  the  bowels  over  a  protracted  period — the  loss  being  to 
the  extent  of  a  dessertspoonful  or  more.  The  condition  found  on 
inspection  varies  with  the  stage  in  which  the  patient  happens  to  be. 
We  may  only  find  a  few  withered  folds  of  skin  or  mucous  membrane 
(fig.  191),  or  a  bunch  of  bluish-red  tense  nodules,  tender  on  pressure, 
or  even  a  wdiole  crown  of  them.  If  the  patient  is  in  the  bleeding 
stage,  one  of  these  nodules  will  be  ulcerated,  and  it  may  be  possible 
to  see  a  black  coagulum  projecting  from  the  point  whence  the 
haemorrhage  occurred.  If  internal  hjemorrhoids  became  thrombosed, 
they  prolapse  very  easily,  and  maybe  strangulated  by  the  sphincter  ani, 
with  such  damage  to  their  circulation  that  necrosis  may  follow.  They 
look  like  bluish-black  or  brownish-black  nodules,  surrounded  by 
oedematous  anal  skin,  or  by  a  ring  of  oedematous  and  swollen  external 
haemorrhoids  (fig.  193).  Further  extension  of  the  inflammation  may 
cause  retention  of  the  urine,  abscesses,  and  even  general  septic 
infection. 

If  the  subjective  symptoms  and  the  haemorrhage  indicate  the 
presence  of  haemorrhoids,  which  are  invisible  on  inspection,  we  must 
endeavour  to  get  the  rectal  mucous  membrane  to  prolapse,  in  order 
to  bring  internal  haemorrhoids  into  view^ 


4IO       SURGICAL   DISEASES   OF   THE   ABDOMINAL   AND   PELVIC   VISCERA 


We 

vvithou 

haeraor 

Vei" 


must  never  assume  the  presence  of  infernal  haemorrhoids, 
t  local  examination,  merely  because  there  are  no  external 
rhoids. 

y  rare  cases  have  been  recorded  wherein  the  haemorrhoids  have 

been  situated  lo  to  20  cm.  above  the 
anus.  The  diagnosis  may  be  suggested 
by  haemorrhage,  but  it  can  really  only 
be  established  by  rectoscopy. 

(c)  A  patient  who  complains  of 
occasional  attacks  of  pain  in  the 
region  of  the  anus,  on  sitting  down 
or  on  defaecation  —  pains  which  in- 
crease for  a  few  days  and  then  sud- 
denly disappear  after  the  evacuation 
of  a  certain  amount  of  pus — is  suffer- 
ing from  a  peri-proctitic  abscess. 
There  may  be  intervals  of  months  or 
years  between  these  attacks,  but  the 
patient  will  sometimes  observe  that 
some  pus  escapes  even  durmg  these 
free  intervals,  indeed  that  flatus  passes 
Fig.  191, — Relaxed  haemorrhoids.  despite   the   firm    contraction    of    the 


Fig.  192. — Inflamed  external  heemorrhoids. 


Fig.    193. — Prolapsed  internal  bremorrhoids 
surrounded  by  external  oedematous  piles. 


sphincter.  In  such  a  case  we  may  conclude  that  the  abscess  has  been 
followed  by  an  anal  fistula  or  a  rectal  fistula.  We  shall  discuss  the 
details  of  the  examination  of  these  tistulae  in  a  separate  chapter. 

{cl)  If  the  pain   occurs   before  defaecation,  rather   than  dnrl/ig  this 


DIFFICULTIES    OF    DEF.i:CATIOX 


411 


act,  and  if  there  be,  at  the  same  time,  pain  on  micturition,  the  case  is 
one  of  prostatitis,  probably  of  gonorrhoeal  origin,  but  possibly  also 
of  a  tubercular  nature, 

(6')  If  the  symptoms  do  not  fit 
in  with  any  clinical  picture,  but 
consist  of  tenesmus,  blood  and 
possibly  pus  in  the  stools,  consti- 
pation, pains  in  the  pelvis,  we 
should  think  of  a  foreign  body. 
We  shall  see  in  the  next  chapter, 
the  variety  of  articles  which  have 
been  introduced  into  the  rectum. 

(6)  Prolapse  of  ilie  Anns. — 
Sometimes  the  difficulty  in  de- 
faecation  consists  of  a  prolapse 
of  the  rectal  mucous  membrane. 
The  diagnosis  can  be  made  by 
a  layman  ;  we  have  to  decide 
whether  the  prolapse  merely  con- 
cerns the  lowest  portion  of  the 
mucous  membrane  —  prolapsus 
ani  —  or  whether  the  mucous 
membrane  higher  up  is  involved 
—  prolapsus  recti  —  or  whether 
both      conditions      are      present 


Fig.  194. — Cancer  of  the  anal  portion  of 
the  rectum. 


FlG.  195.  — Prolapse  of  the  anus  and 
rectum. 

27 


Fig.  196.  —  Sarcoma  of  the  anus. 


412      SURGICAL   DISEASES   OF   THE   ABDOMINAL   AND   PELVIC   VISCERA 

(fig.  195).  Our  decision  must  be  based  on  the  size  of  the  prolapse 
and  upon  the  level  at  which  the  doubling  up  of  the  bowel  is  found — ■ 
at  the  anus  or  higher. 

Prolapsus  ani  is  purely  a  matter  of  mucous  membrane  prolapse. 
In  prolapsus  recti,  all  the  layers  of  the  intestinal  wall  are  turned  in 
and  the  peritoneum  may  even  be  dragged,  so  that  a  perineal  hernia 
may  be  formed — a  so-called  hedrocele. 


CHAPTER  LVI. 
INJURIES  OF  THE  RECTUM. 

Apart  from  lacerations  of  the  intestine  and  rectum  during  labour, 
the  injuries  of  this  region  are  mostly  due  to  impalement  or  to 
foreign  bodies  introduced  for  various  purposes  and  in  different  ways. 

Impalement  may  be  caused  by  falling  on  a  garden  fence,  the 
handle  of  a  broom,  the  barrel  of  a  gun,  or  the  leg  of  a  chair,  &c. 
Agricultural  labourers  are  often  impaled  by  falling  off  a  haystack  on  to 
the  handle  of  a  fork.  The  laceration  of  the  rectum  by  the  horns  of  a 
bull  produces  a  similar  injury  to  impalement.  The  external  wound  is 
easily  recognized  in  all  these  accidents  ;  diagnosis  is  mainly  con- 
cerned with  the  question  of  the  extent  of  the  injury  above.  This  may 
sometimes  be  determined  by  the  length  of  the  tract  of  blood  on 
the  impaling  instrument. 

Some  consideration  should  be  bestowed  upon  the  question  of  the 
possibility  of  a  foreign  body  being  retained  in  the  wound.  The 
following  case,  which  I  saw  when  assistant  to  Kocher,  shows  that  this 
is  not  an  unimportant  matter.  A  young  man,  overstimulated  by 
alcohol,  climbed  up  to  the  top  of  three  chairs  standing  on  each  other. 
The  chairs  fell  over,  and  the  leg  of  one  of  them  penetrated  deeply 
between  his  rectum  and  sacrum.  But  the  wound  seemed  to  be  remark- 
ably harmless,  and  the  rectum  appeared  to  be  uninjured.  The  onset 
of  fever  and  of  offensive  discharge  showed,  however,  that  there  was 
something  wrong.  Just  before  the  demonstration  of  the  patient  in 
the  clinic  the  probe  touched  at  the  level  of  the  promontory  on  a 
peculiar  structure,  the  meaning  of  which  at  once  became  clear. 
During  the  clinical  demonstration  the  seat  of  the  trousers  in  which 
the  four  seams  joined  together  was  triumphantly  extracted  by  the 
forceps.  The  patient  had  changed  his  trousers  before  being  brought 
to  the  hospital,  otherwise  the  hole  would  have  enabled  us  to  make  the 
diagnosis  earlier. 

If  we  are  certain  from  the  length  of  the  penetrating  body  that  the 


INJURIES    OF   THE    RECTUM  415 

peritoneum  has  been  torn,  the  abdomen  must  be  opened  and  searched,, 
so  as  to  avoid  a  belated  diagnosis  of  intraperitoneal  injury  to  the 
intestine,  when  peritonitis  supervenes  after  a  few  days. 

Among  the  foreign  bodies  purposely  introduced,  one  should 
mention  especially  the  nozzles  of  enema  syringes.  Fatal  injuries  have 
been  inflicted  in  this  way,  especially  when  the  enema  is  administered 
into  the  abdominal  cavity.  These  accidents  happen,  naturally,  more 
frequently  when  the  mucous  membrane  is  diseased,  as  in  cancer,  than 
when  it  is  healthy. 

In  contrast  to  an  enema  syringe  employed  for  constipation,  a  wood- 
chopper  in  the  forest  put  a  wedge  of  wood  into  his  rectum,  for 
diarrhoea.  A  colleague  has  informed  me  of  a  case  whei'ein  a  man 
introduced  a  liqueur  glass,  in  order  that  he  might  be  able  to  witness  a. 
festive  procession,  undisturbed.  Sometimes  foreign  bodies  are  used 
for  mastuibation. 

There  is  no  complete  account  of  these  cases  in  literature,  and  the 
most  unique  examples  of  these  occurrences  do  not  exhaust  all  the 
possibilities,  but  in  them  all,  the  patient  complains  of  tenesmus  and 
hcemorrhage.  We  should,  therefore,  never  neglect  a  rectal  examination 
in  any  case  wherein  such  symptoms  come  on,  apparently  without 
cause. 

As  we  cannot  obtain  any  reliable  information  concerning  the 
nature  of  the  foreign  body,  we  must  be  careful  to  protect  the  hnger 
with  a  stall,  to  prevent  injury  to  it.  Inspection  with  a  speculum, 
which  is  sometimes  indispensable  for  the  diagnosis,  should  be  left 
until  the  extraction  is  undertaken,  as  this  requires  anassthesia. 

The  rectum  is  occasionally  injured  during  attempts  to  procure 
abortion.  I  once  made  an  autopsy  on  a  young  girl  who  died  of 
peritonitis  after  an  attempt  at  abortion.  The  posterior  vaginal  wall 
and  Douglas's  pouch  were  perforated  and  the  rectum  was  impaled  : 
The  midwife  who  was  accused  set  up  the  defence  that  she  was  much 
too  experienced  to  have  attempted  to  gain  the  right  orihce  in  this- 
clumsv  manner. 


27A 


414      SURGICAL   DISEASES   OF   THE   ABDOMINAL   AND    PELVIC   VISCERA 

CHAPTER    LVIL 
TUMOURS    AND    SWELLINGS    OF    THE    SCROTUM. 

When  we  are  consulted  for  any  scrotal  swelling,  we  must  first 
determine  whether  the  swelling  originates  in  the  testicles  or  in  the 
scrotum.  This  can  only  be  done  if  it  is  possible  to  feel  the  testicle 
and  its  appendages  quite  distinctly,  apart  from  the  investing  skin. 
But  if  the  swelling,  the  testicle  and  the  skin  all  form  one  connected 
mass,  we  must  depend  upon  the  history  to  tell  us  whether  the  change 
involved  at  first  the  scrotal  contents  only. 


iTjirfiitri  m«si 


Fig.  197.— Acute  exlravasation  of  urine,  in  a  case  of  neglected  urethral  stricture. 


l.-SWELLINGS    OP^   THE    SCROTUM. 

A.— ACUTE    SWELLINGS. 

If  the  swelling  has  arisen  suddenly,  the  first  point  to  consider  is 
the  question  of  contusion,  which  may  cause  a  severe  degree  of  blood 
extravasation.  Then  there  is  the  possibility  of  acute  inflammatory 
diseases,  especially  erysipelas,  or  of  extravasation  ofurine  conse- 
quent upon  an  injury  or  a  neglected  urethral  stricture,  a  matter  of 
the  greatest  importance,  because  the  treatment  depends  upon  the 
accuracy  of  the  diagnosis.  If  one  meets  with  such  a  clinical  picture 
as  is  illustrated  in  fig.  197,  he  must  not  be  content  with  the  diagnosis 


TUMOUKS    AND    SWELLINGS    OF    THE    SCROTUM  415 

of  phlegmon,  &c.,  but  must  at  once  provide  for  the  free  escape  of 
the  urine,  in  order  to  prevent  his  patient  dying  from  uraemia  and 
sepsis. 

B.— CHRONIC    SWELLINGS. 

(i)  If  a  diffuse  swelhng  has  arisen  graduahy,  as  a  result  of  repeated 
acute  inflammatory  attacks,  e.g.,  erysipelas,  or  as  a  consequence  of 
chronic  multiple  urinary  fistulae,  the  term  applied  to  it  is  elephantiasis, 
The  same  name  is  applied  to  the  enormous  hypertrophy,  which  occurs 
in  the  tropics,  from  filarial  disease.  In  this  condition  the  patient  is 
hardly  able  to  walk,  because  of  the  appendage  to  his  scrotum. 

(2)  Circnuiscribed  iiiiiioitrs  of  the  scrotal  skin  are  diagnosed  accord- 
ing to  their  consistence.  If  they  show  fluctuation,  are  soft  or  tensely 
elastic,  they  may  be  dermoids,  sebaceous  cysts  or  cystic  lymphan- 
giomata.  The  former  are  unilocular  and  non-translucent ;  the  last 
are  multilocular  and  translucent,  but  are  distinguished  from  hydrocele 
by  their  superficial  situation. 

If  the  circumscribed  tumour  is  hard,  it  may  be  either  a  fibroma 
or  a  sarcoma,  in  accordance  with  its  rate  of  growth. 

If  the  scrotal  tumour  is  of  an  ulcerating  character,  we  should 
think  instinctively  of  chimney-sweep's  cancer  or  tar  cancer.  We 
should  examine  the  history  from  this  point  of  view,  and  note  whether 
there  be  any  eczema  which  paves  the  way  for  the  cancer,  or  any  so- 
called  soot-warts.  But  if  the  history  does  not  support  this  view^, 
we  should  remember  that  the  scrotum  may  be  a  seat  of  a  primary 
chancre,  and  that  tertiary  ulcers  may  resemble  carcinomata. 

II._SWELLINGS    OF   THE    SCROTAL   CONTENTS. 

If  the  swelling  is  in  relation  with  the  normal  contents  of  the 
scrotum,  we  must  first  ascertain  whether  it  has  a  pedicle  at  its  upper 
part,  in  other  words,  whether  it  runs  into  the  inguinal  canal.  If  this 
should  be  the  case,  the  conclusions  to  be  drawn  are  already  discussed 
in  the  chapter  on  Inguinal  Hernicie. 

In  acute  inflammation  of  the  testicle  and  epididymis  there  is 
nearly  always  some  infiltration  of  the  spermatic  cord,  which  may 
then  resemble  the  pedicle  of  a  tumour,  a  matter  which  will  be  referred 
to  later  on.     The  same  applies  to  advanced  cancer. 

A.— TUMOURS    OF   THE    SPERMATIC    CORD. 

An  elastic  or  tense  swelling  in  connection  with  the  spermatic  cord, 
quite  free  of   the  testicle  and  epididymis,  is  a  funicular  hydrocele, 
The  diagnosis   is  absolutely   certain   if   the  swelling    is,   in   addition, 
translucent. 
27B 


4l6      SURGICAL   DISEASES   OF   THE   ABDOMINAL   AND    PELVIC   VISCERA 

We  have  seen  in  Chapter  LIV.  that  the  acute  hydrocele  of  Httle 
boys  is  often  mistaken  for  strangulated  hernia. 

A  soft  non-translucent  swelling  is  in  all  probability  a  lipoma  of 
the  spermatic  cord  (p.  3^9).  A  hard  tumour,  adherent  within  the 
spermatic  cord,  suggests  the  rare  form  of  sarcoma,  which  grows 
rapidly  towards  the  abdominal  cavity. 

We  now  proceed  to  deal  with  diseases  of  the  testicle  and  epididymis, 
which,  logically,  should  be  considered  separately.  But  as  the 
apparent  position  of  the  swelling  does  not  always  correspond  with 
its  true  topography,  we  propose  to  group  them  together  in  the  first 
instance  and  then,  later  on,  endeavour  to  distinguish  between  the 
testicle  and  epididymis. 

B.— ACUTE    SWELLINGS   OF   THE    TESTICLE    AND 
EPIDIDYMIS. 

Let  us  assume  the  case  of  a  patient  who  consults  us  for  an  acute 
painful  swelling  of  the  scrotal  contents,  and  who  tells  us  that  it  has 
resulted  from  a  blow,  a  statement  which  should  be  taken  cniii  grano 
salis  if  the  patient  is  insured  against  accidents.  We  find  the  testicle 
and  epididymis  fused  together  into  a  very  tender  oval-shaped  mass. 
The  skin  of  the  scrotum  is  slightly  oedematous,  the  spermatic  cord  is 
hard  and  swollen,  and  resembles  a  pedicle  running  into  the  inguinal 
canal,  and  the  vas  deferens  cannot  be  felt  as  a  separate  structure.  If 
Ave  agree  that  an  injury  has  been  the  cause,  we  should  think  of  a 
traumatic  hsematocele,  i.e.,  an  effusion  of  blood  into  the  tunica 
vaginalis  and  into  the  cellular  tissue  of  the  scrotum.  The  diffuse 
swelling  which  obscures  the  division  between  testicle  and  epididymis 
and  the  infiltration  of  the  spermatic  cord  may  very  well  be  attributed 
to  the  oedema  which  accompanies  such  an  injury.  Our  assumption 
will  be  correct  if  the  swelling  exceeds  in  size  the  usual  dimensions 
of  a  recent  orchitis  or  epididymitis,  i.e.,  if  it  is  larger  than  a  goose's 
egg.  Sometimes  confirmation  may  be  obtained  from  a  dark  blue 
discoloration  of  the  scrotum,  especially  on  the  posterior  surface  ;  at 
any  rate  this  discoloration  should  appear  within  a  few  days.  If,  how- 
ever, the  swelling  be  smaller,  and  there  be  no  discoloration  despite 
the  lapse  of  a  few  days  since  the  alleged  accident,  our  thoughts  should 
run  in  another  direction,  although  we  should  not  entirely  discard 
the  traumatic  theory.  Pressure  on  the  urethra  may  cause  a  few  drops 
of  the  anticipated  discharge  to  exude,  and  then  further  discussion  is 
unnecessary,  especiallv  if  the  swelling  mainly  concerns  the  epididymis. 
The  case  is  one  of  gonorrhoeal  epididymitis.  If  we  do  not  obtain 
any  discharge,  which  sometimes  ceases  with  the  onset  of  the  epididy- 
mitis, we  should  inquire  for  the  date  of  the  last  attack  of  gonorrhoea. 
If  this  meets  with  a  negative  reply,  we  should  make  a  rectal  examina- 


TUMOURS    AND    SWELLINGS    OF   THE    SCROTUM  417 

tion,  exerting  slight  pressure  on  the  prostate,  and  then  direct  the 
patient  to  urinate.  Abundant  gonorrhoeal  threads  and  small  flakes 
of  pus  suffice  for  the  diagnosis.  But  if  these  are  not  present,  and 
the  urine  is  somewhat  turbid  and  of  offensive  odour,  containing 
numerous  pus-cells,  micro-organisms,  and  probably  crystals  of  triple- 
phosphate,  we  must  abandon  the  idea  of  gonorrhoeal  epididymitis. 
The  patient  has  cystitis  either  as  the  result  of  stricture,  hypertrophied 
prostate  or  tubercle,  &c.,  and  the  epididymitis  or  orchitis  has  arisen 
owing  to  extension  from  the  bladder.  As  these  infections  are  fre- 
quently caused  by  trifling  injuries,  we  should  ascertain  whether  the 
patient  has  passed  a  catheter  on  himself  or  has  recently  had  one  passed. 

All  this  does  not  exclude  the  possibility  that  gonorrhoea  may  have 
been  the  original  starting  point  of  the  disease.  The  gonorrhoea  may 
have  occurred  years  previously,  and  the  infecting  organism  at  the 
moment  is  not  necessarily  the  gonococcus,  but  an  ordinary  pus 
organism  such  as  the  staphylococcus  or  streptococcus. 

We  may  assume  inflammation  of  this  kind  if  the  testicle  rather 
than  the  epididymis  is  involved.  But  if  no  source  of  infection  is 
discoverable  in  the  uro-genital  apparatus  there  remains  the  possibility 
of  metastatic  orchitis.  This  includes  the  inflammation  of  the 
testicle  which  sometimes  occurs  in  mumps,  and  occasionally  after 
other  infectious  diseases  such  as  typhoid  fever.  Finally,  there  are 
some  very  rare  cases  which  cannot  be  explained,  even  in  this  manner  ; 
the  orchitis  is  apparently  spontaneous  and  has  no  connection  with 
any  other  disease.  The  testicle  is,  as  a  rule,  alone  involved  in  these 
cases,  so  that  the}^  are  easily  distinguished  from  gonorrhoeal 
inflammation. 

If  this  form  of  swelling  appears  to  extend  beyond  the  testicle, 
it  usually  depends  upon  a  slight  attack  of  secondary  hydrocele,  in 
association  therewith.  In  such  a  case  there  would  be  no  sharp 
separation  between  testicle  and  epididymis  ;  but,  as  stated  previously, 
they  would  merge  into  one  oval-shaped  swelling.  In  a  simple  orchitis 
the  epididymis  is  situated  above  the  swollen  testicle  like  a  narrow 
ledge.  On  the  other  hand,  in  a  case  of  simple  epididymitis,  the 
uniformly  enlarged  epididymis  lies  against  the  testicle  like  the  crest 
on  a  helmet. 

If  we  aie  in  doubt  about  the  nature  of  an  orchitic  swelling  owing 
to  the  absence  of  any  accurate  histor}^,  we  may  resort  to  an  explora- 
tory puncture,  lest  we  overlook  a  purulent  inflammation  until  it  is  too 
late  to  save  the  testicle. 

Before  making  the  puncture  we  should  warn  tiie  patient  that  his 
testicle  may  atrophy  as  the  result  of  the  disease,  otherwise  the 
incident  which  happened  to  us,  owing  to  our  neglect  of  this  pre- 
caution, might  be  repeated.  A  young  man  had  a  testicle  as  large  as 
a  plum,  which  was  very  painful  on  pressure  ;  fever  and  pain  persisted 
so  that  a  puncture  was   made  with  a  fine  needle,   but  without  any 


4l8      SURGICAL   DISEASES    OF   THE   ABDOMINAL   AND   PELVIC   VISCERA 

result.  The  inflammation,  however,  subsided,  and  the  patient  was 
discharged.  He  returned  in  a  few  days  looking  very  sad,  because 
not  only  had  the  inflammation  disappeared  but  the  testicle  also,  and 
he  blamed  the  exploratorv  puncture  for  this.  Indeed,  there  only 
remained  a  hard  body,  not  bigger  than  a  bean,  instead  of  the  plum- 
sized  swelhng.  We  had  then  to  ofter  the  explanation  which  we  had 
previously  neglected  to  do  by  way  of  prognosis,  and  the  patient 
finally  consoled  himself  with  the  reflection  that  the  presence  of  one 
testicle  was  sufficient. 

It  happens  occasionally  that,  although  everything  points  to  a 
gonorrhoeal  epididymitis,  we  learn  that  the  patient  has  had  of  late 
more  frequent  calls  to  micturition  than  usual,  the  stream  still  being 
normal,  and  that  he  is  obliged  to  get  up  one  or  more  times  during 
the  night  for  this  purpose.  He  may  have  noticed  a  fine,  whitish 
deposit,  or,  exceptionally,  a  little  blood  in  the  urine.  This  usually 
signifies  the  beginning  of  uro-genital  tuberculosis.  How,  then,  is 
the  acute  onset  of  the  swelling  to  be  explained  ?  This  may  be  due 
to  an  acute  perforation  of  a  tubercular  focus  into  the  tunica  vaginalis, 
with  a  consequent  tubercular  hvdrocele.  Examination  would  show 
tliat  the  epididymis  cannot  be  separately  defined  from  the  testicle, 
and  that  the  latter  appears  to  be  enlai-ged,  and  may  even  present 
fluctuation.  Or  it  may  be  that  the  epididymitis  is  not  purely  of 
a  tubercular  nature.  There  may  have  been  a  nodule  which  the  patient 
had  not  noticed,  and  it  may  have  become  secondarily  infected,  a 
circumstance  which  often  happens  in  uro-genital  tuberculosis,  even 
if  catheterization  has  not  been  practised.  Examination  of  the  urinary 
sediment  shows  mononuclear  and  polynuclear  leucocytes,  possibly 
a  few  red  cells  also,  epithelial  cells.  Bacillus  coU,  staphylococci  and 
streptococci.  As  the  disease  progresses  an  abscess  will  probably  form 
in  the  epididymis,  and  spontaneous  rupture  finally  occurs. 

Contusion  of  the  testicle  and  the  various  forms  of  inflammation 
do  not,  however,  exhaust  all  the  possible  causes  of  acute  swelling. 
If  the  symptoms  have  come  on  very  suddenly,  and  are  accompanied 
by  such  reflex  signs  as  vomiting,  retention  of  flatus,  if  the  swelling 
is  somewhat  high  up  and  we  are  informed  by  the  patient  that  his 
testicle  had  never  completely  descended,  we  should  think  of  torsion 
of  the  testicle,  a  condition  already  referred  to  in  connection  with 
strangulated  hernia.  The  results  of  this  torsion  are  ha3morrhagic 
infarction  and  gangrene  of  the  testicle  (p.  399). 

The  anatomical  basis  of  this  event  is  an  abnormally  developed 
mesentery  of  the  testicle,  Avhich  permits  it  to  hang  free  in  the  tunica 
vaginalis.  The  only  condition  with  which  it  could  possibly  be 
mistaken  is  an  embolic  infarction  of  the  testicle  occurring  in  a  patient 
with  heart  disease. 


TUMOURS    AND    SWELLINGS    OF   THE    SCROTUM  419 

C— CHRONIC   SWELLINGS   OF    THE  TESTICLE   AND 

EPIDIDYMIS. 

Although  we  are  not  able  to  clearly  distinguish  the  testicle  from 
the  epididymis  when  they  are  acutely  swollen,  this  distinction  is 
somewhat  more  possible  in  the  early  stages  of  chronic  swellings. 

(1j  Swellings  of  the    Epididymis. 

If  the  epididymis  is  hard  and  swollen  in  an  irregularly  nodular 
manner,  or  if  a  hard,  tender  nodule  is  felt  in  an  otherwise  normal 
organ,  we  should  immediately  think  of  tuberculosis.  We  seek  for 
confirmation  of  this  diagnosis  in  the  characteristic  nodular  or 
cylindrical  thickening  of  the  vas  deferens,  which  is  early  recognized 
because  the  vascular  elements  of  the  cord  usually  feel  quite  normal 
when  the  tubercle  is  not  accompanied  by  secondary  infection,  in 
contrast  to  what  wc  have  seen  in  acute  orchitis,  gonorrhoeal  epidi- 
dymitis, and  tubercle  with  secondary  infection.  If  the  vas  deferens 
is  not  thickened,  we  must  look  for  traces  of  tubercle  in  the  prostate, 
bladder,  kidneys,  as  described  in  fuller  detail  in  the  chapter  on  uro- 
genital tuberculosis.  The  kidney  is  often  the  organ  first  affected, 
and  the  disease  of  the  epididymis  is  only  detected  first  because  of  its 
accessibility. 

There  are  three  conditions  with  which  this  early  stage  of  tuber- 
culous epididymitis  ma}^  be  confused  : — 

(a)  The  reiiuiiiis  of  gonorrliCEal  epididymitis,  hard,  somewhat 
tender,  indurations  in  the  epididymis.  The  distinction  is  made  by 
the  history  and  other  physical  findings,  especially  by  a  careful 
examination  of  the  urine. 

(6)  Syphilitic  epididyiiiitis  of  the  secondary  stage,  recognized  by  its 
almost  painless  onset  and  other  diagnostic  signs  of  syphilis. 

(c)  A  small  cyst  connected  with  the  head  of  the  epididymis — 
spermatocele.  Its  striking  mobility,  the  smoothness  of  its  surface, 
and  its  painlessness  settle  the  diagnosis. 

But  if  we  do  not  see  the  patient  until  a  later  stage  of  the  disease, 
when  he  has  an  old,  retracted,  slightly  discharging  sinus,  the  problem 
is  quite  different.  Testis  and  epididymis  are  fused  together  into  one 
shapeless  mass  and  cannot  be  felt  separately.  The  principal  question 
to  decide  is  whether  the  case  is  one  of  tubercle  or  tertiary  syphilis. 
A  gumma  attacks  the  testicle  by  preference,  while  tubercle  starts  in 
the  epididymis.  The  patient  may  perhaps  be  able  to  inform  us  of 
the  original  site  of  the  disease,  iDut  if  he  cannot  do  so  we  should 
diagnose  a  gumma  when  the  epididymis  is  only  slightly  involved 
and  the  testicle  considerably  affected,  especially  if  spontaneous  pain 
and  tenderness  are  but  slight. 

If  a  sinus  has  already  formed  it  is  convenient  to  remember  Reclus' 


420       SURGICAL   DISEASES   OF   THE    ABDOMINAL   AND   PELVIC   VISCERA 

sign,  to  the  effect  that  a  syphiHtic  sinus  generally  lies  ///  front  and 
that  a  tubercular  sinus  lies  behind,  corresponding  to  the  situation 
of  the  two  diseases  in  the  testicle  and  epididymis  respectively. 

One  must  not  forget,  however,  that  if  the  testicle  is  inverted  a 
tubercular  sinus  may  lie  forward.  It  is  therefore  necessary  to 
observe  the  position  of  the  vas  deferens  in  the  spermatic  cord  to 
see  whether  it  is  in  front  or  behind,  before  drawing  any  conclusion 
from  the  situation  of  the  sinus. 


(2)  Swellings  between    the   Testicle   and    Epididymis. 

Cystic  tumours  lying  between  the  head  of  the  epididymis  and  the 
testicle,  and  seated  on  the  latter  like  a  cap  or  helmet,  are  grouped 
together  under  the  term  spermatocele.  When  such  a  cyst  is  present 
it  is  either  impossible  to  feel  the  head  of  the  epididymis  as  a  separate 
structure,  or  it  lies,  as  just  stated,  on  the  spermatocele,  so  that  the 
latter  is  tixed  between  it  and  the  testicle.  In  order  to  render  the 
diagnosis  more  certain  an  exploratory  puncture  may  be  performed, 
which,  although  generally  superfluous,  never  does  any  harm  if  asepsis 
is  preserved.  The  diagnosis  is  confirmed  by  the  turbid  watery 
appearance  of  the  liquid,  and  by  the  presence  of  seminal  threads 
visible  under  the  microscope. 

(3)  Swellings  of  the  Testicle. 

{a)  An  oval  or  pear-shaped  tumour  with  a  smooth  surface  and  of 
soft  or  tensely  elastic  consistence,  indicates  an  accumulation  of  fluid 
in  the  tunica  vaginalis.  If  it  be  of  small  extent,  the  epididymis  can 
still  be  appreciated  as  a  separate  structure,  and  we  may  ev^en  be  able 
to  feel  the  testicle  [if  the  fluid  is  not  very  tense.  If,  however,  the 
swelling  is  large  and  the  tension  greater,  both  testicle  and  epididymis 
only  present  somewhat  more  resistant  places  in  the  wall  of  the  swelling. 
If  the  effusion  has  a  thick  wall,  it  may  be  quite  mipossible  to  define 
them.  The  case  is  one  of  hydrocele  or  hsematocele  of  the  testis,  a 
serous  or  proliferating  or  haemorrhagic  peri-orchitis,  which  may 
vary  in  size  from  a  hen's  egg  to  enormous  proportions,  if  the  patient 
waits  until  it  is  necessary  to  draw  off  the  fluid  by  the  pint. 

If  the  swelling  is  translucent  it  is  a  hydrocele,  and  puncture  is  then 
not  merely  an  exploratory  procedure,  but  is  a  therapeutic  measure,  at 
any  rate  of  a  palliative  nature. 

If  puncture  of  a  tense  translucent  swelling  is  not  followed  by  a 
flow  of  fluid,  we  should  not  diagnose  cancer  as  a  young  practitioner 
once  did,  but  rather  a  bad  syringe. 

If,  however,  the  swelling  is  not  translucent,  the  diagnosis  is  usually 
proliferating  peri-orchitis,  i.e.,  a  hydrocele  whose  wall  has  become 
thickened  by  connective  tissue  proliferation,  by  crest-  and  cone-like 


TUMOURS   AND   SWELLINGS   OF   THE   SCROTUM  42 1 

indurations,  and  by  deposits  of  gradually  organizing  fibrin.  If,  on 
exploratory  puncture,  a  fresh  bloody  fluid,  or  more  frequently  a 
chocolate-brown  fluid,  exudes,  the  case  is  one  of  haematocele,  which 
we  must  look  upon  as  a  sub-variety  of  proliferating  peri-orchitis,  when 
it  is  not  of  traumatic  origin. 

Serous  peri-orchitis,  as  well  as  the  proliferating  and  haemorrhagic 
forms,  give  rise,  in  different  ways,  to  many  points  of  differential 
diagnosis. 

A  serous  pcri-orcliiiis,  associated  with  appreciable  changes  in  the 
testicle  and  epididymis,  may  be  secondary  or  symptomatic.  Such 
effusions  within  the  tunica  vaginalis  occur  in  herniae,  tubercular  epi- 
didymitis, and  cancer  of  the  testicle  ;  but  they  rarely  become  so  large 
that  the  underlying  disease  is  obscured.  If  we  find  that  the  upper 
end  of  a  hydrocele  which  extends  high  up  is  very  painful  on  pressure, 
and  that  there  is  probably  some  thickening  of  the  spermatic  cord  at 
this  spot,  it  is  very  likely  that  a  fragment  of  onieninni  has  become 
strangulated  in  a  communicating  sac  with  a  narrow  neck,  so  that  the 
hydrocele  is  another  instance  of  the  secondary  form  (p.  38S).  In  a 
case  of  proliferating  peri-orchitis,  our  diagnostic  reflections  take  another 
direction,  at  any  rate  before  an  exploratory  puncture  is  done.  A 
malignant  groivtli  will  very  frequently  suggest  itself ;  unequal  con- 
sistence usually  indicates  a  tumour,  although  in  simple  proliferating 
peri-orchitis  its  wall  may  present  soft,  thin  areas  as  well  as  hard  ones. 
A  rough  nodular  surface  is  clear  evidence  of  new  growth.  Some 
tumours,  however,  have  a  perfectly  smooth  surface  in  their  initial  stage. 
As  the  infallible  signs  of  a  malignant  growth,  i.e.,  enlargement  of  the 
retroperitoneal  glands  of  the  same  side  and  other  metastases,  are 
absent  at  the  beginning,  we  must  fall  back  upon  the  history.  A  simple 
proliferating  or  haemorrhagic  peri-orchitis  has  usually  existed  for 
months,  or  even  years,  whereas  a  malignant  tumour  can  only  have 
been  present  at  most  for  a  few  months. 

There  is  nothing  absolutely  conclusive  in  these  signs,  because  a 
haematocele  may  develop  very  rapidly  after  an  injury,  and  some 
malignant  tumours  grow  very  slowly.  I  once  saw  a  malignant  tumour 
w^hich  had  been  under  the  observation  of  the  family  practitioner  for 
many  years.  These  are,  however,  exceptional  cases,  and  the  practical 
rule  remains  that  the  duration  of  haemorrhagic  peri-orchitis  is  a  matter 
of  years,  while  that  of  cancer  or  sarcoma  is  a  matter  of  months. 

After  having  taken  all  these  points  iuto  consideration,  puncture 
with  a  sufficiently  strong  and  wide  cannula  is  justiBable. 

In  proliferating  or  haemorrhagic  peri-orchitis,  a  serous  or  morbid 
chocolate-coloured  liquid  or  fresh  blood  is  obtained  ;  from  a  tumour, 
however,  nothing  is  forthcoming,  or  at  most  a  few  drops  of  blood,  or 
a  plug  of  tumour  tissue  may  be  found  in  the  needle.  The  latter  is 
useful  for  histological  examination.  If  exploratory  puncture  yields 
nothing  at  one  spot,  whereas  some  mucous  fluid  is  obtained  at  another 


422       SURGICAL    DISEASES    OF    THE    ABDOMIXAL    AXD    PELVIC    VISCERA 

spot,  we  should  diagnose  a  cystic  adeiioiiia.  If  the  fluid  is  of  a  Hght 
brown  colour  like  cafe-an-lait,  and  contains  epithelial  cells,  detritus 
and  cholesterin  crystals,  the  case  is  a  dennoid,  or  at  any  rate  an 
embryoma  of  similar  constitution  to  the  much  more  frequent  ovarian 
dermoids,   both  of  which   may  undergo   cancerous   degeneration 

The  state  of  the  testicle  and  epididymis  is  of  no  significance  in 
cases  of  old-standing  proliferating  and  haemorrhagic  peri-orchitis, 
because  both  these  structures  become  atrophied  and  absorbed  in  the 
indurated  cvstic  wall. 

If  the  clinical  picture  of  proliferating  or  haemorrhagic  peri-orchitis 
is  combined  with  signs  of  acute  local  inflammation,  with  fever,  and 
probablv  even  with  rigors,  we  should  remember  that  these  forms  of 
peri-orcliitis  may  easily  become  infected,  and  we  should  inquire 
whether  there  has  been  any  therapeutic  interference,  such  as  puncture 
or  injection  of  iodine. 

{h)  The  diagnosis  is  very  much  easier  when  there  is  a  solid  tumour, 
definitely  connected  with  the  testicle  and  independent  of  the  epididy- 
mis, or  when  both  testicle  and  epididymis  are  fused  together  into  one 
uneven  tumour.  If  neuralgic  pains  are  present  in  tlie  spermatic  cord 
there  is  no  doubt  about  its  malignancy;  but  it  is  not  always  possible 
to  tell  from  the  clinical  signs  whether  it  is  sarcoma  or  carcinoma, 
a  differentiation  which  is  not  always  easy,  even  after  histological 
examination. 

A  cystic  adenoma  or  cystoma  of  the  testicle  is  a  very  rare  tumour, 
but  we  should  bear  it  in  mind  if  the  swelling  is  irregularlv  roundish  and 
nodular  and  contains  both  hard  and  soft  areas,  and  if  the  above 
mentioned  mucous  fluid  is  obtained  on  exploratory  puncture. 

It  is  important  to  distinguish  cancer  and  sarcoma  from  the  swellings 
described  by  Wilms  as  euibryoid  tumours,  which  are  derived  from  all 
the  three  layers  of  the  embryo  and  grow  in  an  erratic  manner.  The 
dermoids  or  embryomata  just  mentioned  are  innocent  tumours,  but 
these  embryoid  tumours  behave  clinically  like  cancer,  and  can  only  be 
distinguished  microscopically.  A  tumour  of  an  inguinal  testicle  may 
very  probably  be  of  this  nature,  at  any  rate,  such  has  been  my 
experience. 

Tertiary  syphilis  of  the  testicle — either  as  a  single  gumma  or  a 
diffuse  gummatous  sclerosis — is  the  only  disease  which  may  lead  to 
error  in  regard  to  moderately  sized  tumours  limited  to  the  testicle.  If 
there  are  no  metastases,  and  if  we  have  no  very  good  reason  to 
definitely  exclude  tertiary  syphilis,  iodide  of  potassium  should  always 
be  given.  But  if  no  result  follows,  operation  must  be  undertaken, 
because  cancer  of  the  testicle  soon  gives  rise  to  secondar}^  deposits, 
and  therefore  the  organ  must  be  removed  without  hesitation. 

A  word  with  reference  to  accidents.  How  much  attention  should 
be  paid  to  the  assertions  of  insured  patients  that  these  various  diseases 
have  come  on  after  an  injury  ?  It  is  undoubted  that  even  tumours 
may  have  a  traumatic  basis.     Such  a  sequence  is,  however,  very  rare, 


FISTUL.9£   IN   THE   PERINEAL   REGION 


423 


and  it  is  very  necessary  to  ascertain  in  every  case  whether  there  was 
not  some  morbid  change  present  before  the  accident.  This  also 
apphes  to  tubercle.  It  is  also  a  fact  that  tlie  onset  of  gonorrhoea! 
epididymitis  is  favoured  by  injury  ;  but  this  is  no  justification  for 
claiming  workmen's  compensation,  when  the  testicle  has  only  been 
subject  to  the  ordinary  impact  it  may  encounter  during  work,  and  its 
possessor  has  previously  provided  the  necessary  gonococci.  This 
would  be  a  defiance  to  the  aims  of  accident  insurance. 


CHAPTER  LVIII. 
FISTULA  IN  THE  PERINEAL  REGION. 

The  perineal  region,  the  seat  of  various  natural  apertures,  is  also 
the  gathering  place  of  various  fistulae,  some  of  which  are  congenital, 
while  others  only  appear  in  later  life.  The  principle  of  classification 
which  we  will  adopt  depends  upon  the  site  of  origin  of  these  fistulje. 
The  period  of  their  appearance  is  not  a  satisfactory  basis  for  classifica- 
tion, because  even  congenital  fistulae  may  not  develop  fully  for  many 
years.  Neither  can  classification  be  based  upon  their  position,  because 
similar  fistulae  may  have  very  different  situations.  Sometimes  micro- 
scopic examination  is  required  to  decide  the  nature  of  the  discharge 
from  the  fistula. 

We  distinguish : — 

(1)   DERMOID 
FISTUL/E. 

A  fistula  in  the 
coccygeal  area,  dis- 
charging a  small 
amount  of  secretion, 
which  has  been  pre- 
sent for  many  years 
and  which  admits  a 

probe  into  a  short  blind  sac,  is  a  dermoid  fistula.  The  diagnosis  is 
confirmed  if  on  miscroscopic  examination  there  be  found  not  only 
pus,  but  also  pavement  epithelium  and  even  hairs. 

The  patient  who  had  the  fistula  depicted  in  fig.  198,  drew  out 
many  hairs  from  it,  with  the  aid  of  a  mirror. 


Fig.  198.— D  =  Dermoid  fistula.     F  =  Foveola  coccygea. 


424      SURGICAL   DISEASES   OF   THE   ABDOMINAL   AND    PELVIC   VISCERA 

Apart  from  these  embryonic  invaginations,  there  is  often  found  in 
this  region  a  depression,  the  foveola  coccygea  (fig.  198)  which  corre- 
sponds to  the  point  of  attachment  of  the  caudal  hgament  to  the  skin. 

(2)  FISTUL>!E    IN    CONNECTION    WITH    BONE. 

These  are  ahnost  always  tubercular,  and  usually  originate  in  the 
sacrum  or  ileo-sacral  joint ;  more  rarely  in  the  coccyx  or  spinal 
column.  The  discharge  from  these  fistulas  is  always  purulent,  and  the 
probe  introduced  reaches  down  to  bone. 

We  can  draw  no  conclusion  as  to  the  origin  of  these  iistulae  from 
the  histological  demonstration  of  tubercle,  because  many  simple  rectal 
fistulae  are  tubercular,  and  it  is  just  from  these  that  the  differential 
diagnosis  has  to  be  made.  Neither  do  negative  results  justify  any 
definite  conclusion,  because  the  fistula  may  still  be  coming  from  bone, 
affected  by  osteo-myelitis. 

Even  if  a  fistula  comes  from  bone,  we  are  not  justified  in  exclud- 
ing the  possibility  of  all  connection  with  the  rectum.  The  abscess 
may  have  opened  secondarily  into  the  rectum  before  appearing  at  the 
perinaeum. 

An  unequivocal  proof  for  its  bony  origin  is  only  obtained  if  a 
skiagram  shows  the  presence  of  a  primary  focus  in  the  bone,  or  if  this 
focus  (vertebro-ileo-sacral  tuberculosis)  begins  to  manifest  clinical 
symptoms. 

(3)  FISTUL/E    OF   THE    RECTUM   AND   ANUS. 

{a)  Cougeuitcil  Fistnkv. — These  may  be  referred  to  three  types,  in 
accordance  with  the  degree  of  occlusion  and  the  sex  of  the  patient  : — 

(i)  The  anal  aperture  is  itself  reduced  to  the  size  of  a  narrow  fistula, 
which  opens  either  in  the  anal  cleft,  the  scrotum  or  penis. 

(2)  The  anus  is  closed,  and  the  ampulla  is  connected  by  a  fistula 
with  the  vagina,  or  more  frequently  with  the  vestibulum. 

(3)  The  anus  is  closed,  and  the  ampulla  opens  into  the  urethra. 
The  state  of  the  anal  fossa  and  the  position  at  which  the  faeces  escape 
permit  an  accurate  diagnosis  to  be  made  forthwith. 

(b)  Acquired  Inflaniinatory  Fistulce. — These  are  usually  the  final 
results  of  peri-rectal  abscesses,  which  open  externally  near  the  anal 
aperture,  and  generally  also  break  through  somewhere  in  the  rectum. 
They  cannot  be  recognized,  as  a  beginner  might  suppose,  by  the 
escape  of  faeces  therefrom,  for  they  are  usually  much  too  small  for 
this.  Besides,  many  of  them  are  situated  entirely  below  the  sphincter, 
and  others,  despite  their  name,  have  no  opening  in  the  rectum.  A 
fistula  which  has  burrowed  through,  and  opened  above  the  sphincter, 
may,  however,  sometimes  allow  flatus  to  pass  involuntarily.  Before  a 
fistula  can  be  designated  either  rectal  or  anal,  it  ought  to  be  shown 
that  the  original  inflammatory  process  started  in  the  rectum  or  anus. 


FISTULA.    LV   THE   PERINEAL   REGION 


425 


This  is  not  possible,  as  a  rule,  and  therefore  our  diagnosis  is  even- 
tually made  by  exclusion;  that  is  to  say,  a  fistula  in  this  region  is 
either  rectal  or  anal  in  the  narrow  sense,  if  we  can  find  no  other 
explanation  for  it. 

The  portal  of  en- 
try for  the  infection 
is  very  varied.  The 
infective  process 
may  have  become 
engrafted  on  a  fis- 
sure, a  haemorrhoid, 
an  accidental  wound, 
a  simple  eczema,  or 
even  On  a  urethritis. 
In  other  cases  the 
infection  probably 
attacks  peri  -  rectal 
tubercular  glands. 

At  other  times 
the  infection  may 
enter  through  the 
folds  of  Morgagni 
(Chiari),  or  through 
Hermann's  sinus,  in 
which  certain  glands 
described  by  this 
observer  open — this 
sinus  itself  opening 
into  Morgagni's 
folds  (Tavel).  These 
fistulae  are  invested 
with  pavement  epi- 
thelium. In  order  to 
determine  whither 
the  fistula  leads,  the 
bowel  must  be  emp- 
tied and  the  patient 
placed  in  the  lith- 
otomy position  and 
a  moderately  thick 
probe  is  passed  into 
the  fistula  with  one 
hand,  while  the  in- 
dex finger  of  the 
other  is  in  the  rectum  for  purposes  of  control.  If  we  obtain  no  result 
the  examination  must  be  repeated  after  the  introduction  of  a  rectal 
speculum.     If  no   connection   is  even  then  visible  a  sausage-shaped 


Fig.  199.— Diagrammatic  view  of  anal  fistulse. 

m  =  Mucous  membrane  of  rectum. 
r_=  Muscular  layer  of  rectum. 
Si  =  Internal  sphincter. 
Se  =  External  sphincter. 
1  =  Levator  ani. 
J  =  Ischium. 

1  =  Incomplete  submucous  fistula. 

2  =  Incomplete  subcutaneous  fistula. 

3  =  Complete  subcutaneous  fistula. 


^  m 


Fig.  200. — Diagrammatic  view  of  anal  and  rectal  fistulse. 

Anatomical  details  as  in  fig.  199. 

4  =  Incomplete  ischio-l'ectal  fistula. 

5  =  Complete  ischio-rectal  fistula. 

6  =  Incomplete  pelvi-rectal  fistula. 

7  =  Complete  pelvi-rectal  fistula. 

8  =  Fistula  leading  from  tuber  ischii. 


426      SURGICAL   DISEASES   OF   THE    ABDOMINAL   AND    PELVIC   VISCERA 

roll  of  gauze  should  be  gently  put  into  the  rectum  as  high  up  as 
possible  and  the  external  opening  of  the  fistula  injected  with  a  few 
cubic  centimetres  of  a  i  per  cent,  solution  of  methylene  blue.  If  there  is 
any  connection  between  the  fistula  and  the  bowel  there  will  be  a  blue 
stain  on  the  gauze  when  extracted,  which  will  also  show  its  position. 
If  there  is  no  connection  we  must  see  whether  the  probe  reaches  bone, 
and  if  not,  must  observe  whether  the  injected  solution  appears  in 
the  urethra  instead  of  in  the  rectum.  If  all  these  examinations  yield 
negative  results  we  must  still  regard  the  fistula  as  a  rectal  fistula, 
although  it  does  not  open  into  the  rectum.  But,  on  the  contrary, 
we  must  not  suppose  that  every  fistula  which  opens  into  the  rectum 
is  a  rectal  fistula,  as  we  have  already  indicated.  Both  fistula  from 
bones  and  from  the  urinary  tract  may  form  secondary  connections 
with  the  rectum. 

A  fistula  which  penetrates  right  through  is  called  complete,  one 
which  ends  blindly  is  called  incouiplete.  If  it  runs  between  the 
external  sphincter  and  the  skin  or  the  mucous  membrane  we  speak  of 
a  subcutaneous  or  a  submucous  fistula  respectively.  If  it  lies  out- 
side the  external  sphincter  and  under  the  levator  ani  we  call  it  ischio- 
rectal. If  such  a  fistula  is  complete  it  usually  opens  just  above  the 
external  sphincter,  between  it  and  the  internal  sphincter.  If  a  fistula 
pierces  through  the  levator  ani  it  is  called  pelvi-rectal.  If  there  is  an 
internal  opening  to  it,  it  will  be  found  above  the  internal  sphincter 
(fig.  200). 

In  regard  to  the  treatment  and  prognosis  we  are  confronted  with 
the  question  whether  the  disease  is  tubercular,  as  it  is  in  half  the 
cases,  or  whether  it  is  not.  The  very  appearance  of  the  fistula  may 
convey  some  meaning  to  the  careful  observer,  and  he  will  entertain 
a  deep  suspicion  of  tubercle  if  the  skin  is  undermined  and  the 
granulations  pale  brown,  just  as  he  would  if  apical  tuberculosis  had 
been  found  beforehand,  although  the  patient  may  have  had  no  pre- 
sentiment of  it.  Positive  proof  is  afforded  by  histological  examination 
of  the  granulations,  and  in  doubtful  cases  by  animal  inoculation. 

(4)  URINARY  FISTUL/E. 

These  are  easily  recognized  and  easily  diagnosed,  because  a  dis- 
charge of  urine  is  an  unmistakable  symptom,  and  one  which  the 
patient  realizes  at  a  very  early  stage. 

{a)  We  will  begin  with  congenital  nrinaryfistnlce.  These  obviously 
only  occur  in  males  and  are  caused  by  the  urethra  opening  in  the 
perinseum — hypospadia,  scrotal  is  and  perinealis — or  in  the  rectum. 
This  hypospadias  merges  into  hermaphroditism. 

(6)  Acquired  urinary  fistulae  are  of  greater  importance.  We  shall 
not  refer  to  urogenital  fistulae  of  females,  which  belong  to  the  depart- 
ment of  gynaecology,  but  shall  limit  ourselves  to  the  male  sex. 


GENERAL   REMARKS   ON   DISEASES   OF   THE   URINARY   ORGANS      427 

The  first  question  to  decide  is  the  source  of  the  fistula.  The 
mode  and  manner  of  the  urinary  flow  may  be  conclusive  on  this 
point.  If  it  is  constantly  dripping  the  fistula  must  run  into  the 
bladder,  or  some  previous  disease  must  have  destroyed  the  action 
of  the  sphincter. 

This  form  of  fistula  is  rare.  I  have  seen  it  in  an  old  prostatic 
patient  in  whom  a  retroprostatic  pouch  had  led  to  an  extravasation 
of  urine  towards  the  perinaeum,  and  therewith  to  the  formation  of 
a  fistula. 

On  the  other  hand,  if  urine  only  exudes  at  the  time  that  the 
patient  micturates  voluntarily,  not,  however,  through  the  natural 
opening,  but  through  more  or  less  numerous  fistulae,  it  follows  that  the 
urethra  must  be  leaking  between  the  sphincter  and  some  obstruction 
peripheral  to  it. 

The  spot  at  which  the  urine  escapes  is  a  matter  of  indifference. 
One  finds  sometimes,  as  a  result  of  extensive  urinary  infiltration, 
fistulae  on  the  scrotum,  penis,  perinaeum,  lower  abdomen,  and  even 
on  the  thigh,  so  that  the  patient  eventually  micturates  as  from  a  basin 
full  of  holes. 

If  the  distinction  between  fistulae  from  the  bladder  and  from  the 
urethra  is  once  made,  the  etiology  follows  naturally.  In  cases  of 
vesical  fistula  the  obstruction  must  be  at  the  neck  of  the  bladder, 
and  consists  either  of  a  tumour  or  prostatic  hypertrophy.  In  cases 
of  urethral  fistula  the  obstruction  must  lie  peripherally  to  the  neck 
of  the  bladder,  and  consists  of  gonorrhoeal  or  traumatic  stricture, 
rarely  of  tubercle  or  cancer  ;  but  in  the  Tropics  Bilharzia  disease  is 
frequent. 

The  fistulae  which  develop  after  open  injuries,  and  which  concern 
the  urethra  rather  than  the  bladder,  follow  no  rule.  The  same  applies 
to  the  fistulae  which  develop  in  consequence  of  malignant  growths  of 
the  urethra  or  anus. 


CHAPTER  LIX. 


GENERAL  REMARKS  ON  THE  SURGICAL  DISEASES 
OF  THE  URINARY  ORGANS. 

The  cystoscope,  catheterism  of  the  ureters,  the  intravesical  separa- 
tion of  the  urine,  and  cytoscopy,  may  have  improved  the  accuracy  of 
diagnosis  of  urinary  disease,  but  it  has  certainly  robbed  it  of  sim- 
plicity, and  there  is  a  risk  that  the  practitioner  will  think  that  urinary 
disease,  with  the  exception  of  nephritis,  cannot  be  diagnosed  without 
all  these  accessories.     This  would  be,  however,  a  grave  error,  and  the 

28 


428       SURGICAL   DISEASES   OF   THE   ABDOMINAL   AND    PELVIC   VISCERA 

exaggerated  significance  which  was  at  first  attributed  to  some  of  these 
methods  is  to  blame.  The  general  practitioner  still  sees  urinary  troubles 
in  their  earliest  stages,  and  the  responsibility  rests  upon  him  of  recog- 
nizing when  surgical  assistance  is  required.  Every  practitioner  has, 
or  should  have,  a  microscope  at  his  disposal,  and  is  conversant  with 
the  elementary  methods  of  the  chemical  and  bacteriological  examina- 
tion of  the  urine.  These  two  aids,  in  addition  to  careful  clinical 
observation,  permit  the  diagnosis  to  be  made  in  most  cases  sufficiently 
early  for  timely  surgical  treatment — if  this  is  attainable. 

We  will  not  proceed  to  consider  ready-made  diagnoses  like  the 
headings  of  a  text-book,  but  will  take  the  symptoms  which  lead  the 
patient  to  the  medical  attendant.  These  consist  either  of  some  dis- 
turbance in  micturition  or  of  some  abnormal  constitution  of  the 
urine.  Then  there  come  into  consideration  local  symptoms  in  the 
area  of  the  diseased  organ. 

/i.— DISTURBANCES  OF  MICTURITION. 

Micturition  may  be  painful  (dysuria)  or  diijicult  (retention),  or,  on 
the  other  hand,  it  may  be  too  free  (incontinence),  or,  finally,  there 
may  be  a  persistent  strangury  (tenesmus).  Involuntary  micturition, 
which  is  otherwise  normal,  has  only  rarely  a  surgical  interest. 

(1)   PAINFUL  MICTURITION. 

Pain  on  micturition  may  originate  either  in  the  urethra  or  in  the 
bladder  and  its  vicinity.     We  distinguish  the  following  possibilities  : — 

(i)  If  the  urine  scalds  when  it  passes  through  the  nrethra,  there 
is  either  some  abnormality  in  its  composition  (concentrated,  or 
chemically  changed),  or  the  urethra  is  inflamed.  The  former  con- 
dition may  be  caused  by  indulgence  m  certain  beers,  or  by  taking 
beer  to  which  one  is  not  accustomed  ("  biertripper ").  In  recent 
urethritis  it  will  not,  as  a  rule,  be  difficult  to  fix  the  blame  on  the 
gonococcus. 

The  observer  must  convince  himself  of  the  condition  of  the 
urethra  by  inspection,  lest  he  treat  a  gouty  urethritis  for  a  gonorrhoea. 
The  differential  diagnosis  is  easy,  because  there  is  no  discharge  in  the 
former,  whereas  in  the  latter  it  is  always  present  in  some  form. 

A  pain  which  originates  in  the  bladder  is  sometimes  referred  to 
the  urethra,  and  the  patient  complains  of  a  scalding  in  the  glans 
penis,  when,  for  instance,  the  bladder  is  irritated.  Pain  on  micturition 
may  also  arise  from  some  localized  disease  of  the  urethra,  a  stone,  a 
foreign  body  introduced  from  without,  or  rarely  from  the  early  onset 
of  carcinoma, 

(2)  Pain  in  the  neighbourJwod  of  the  bladder,  especially  at  the  end 
of  micturition,  indicates  disease  in  the  bladder  itself  or  in  its  vicinity. 


GENERAL    REMARKS    ON    DISEASES    OF   THE    URINARY    ORGANS      429 

(a)  Stone  and  tuberculosis  are  the  principal  diseases  of  the  bladder 
in  this  connection.  Tumours  do  not  cause  pain  until  their  later 
stages,  unless  cystitis  supervenes.  In  tuberculosis,  and  more  especially 
in  stone,  the  pain  occurs  chiefly  at  the  end  of  micturition,  remains  a 
long  time  after  the  completion  of  the  act,  and  may  radiate  into  the 
urethra. 

In  cases  of  stone  there  is  the  very  significant  circumstance  that 
the  pain  and  the  accompanying  strangury  increase  with  bodily 
movements,  such  as  riding  on  an  uneven  road. 

(6)  When  the  inflammatory  process  is  in  the  area  adjacent  to  the 
bladder,  as  in  the  case  of  perimetritis  or  of  appendicitis,  &c.,  wherein 
the  bladder  is  directly  involved  in  an  abscess  wall,  the  pain  occurs 
at  the  beginning  of  micturition  and  remains  more  limited  to  the 
neighbourhood  of  the  bladder;  patients  with  appendicitis  often  retain 
their  urine  for  many  hours  to  avoid  this  pain.  The  same  applies, 
although  in  a  less  degree,  to  the  bladder  pain  which  often  occurs  in 
cases  of  tubercular  peritonitis. 

(2)    DIFFICULT    MICTURITION. 

This  is  caused  either  by  some  disturbance  of  the  mechanism  or 
by  obstruction  in  the  passage. 

Whenever  there  is  no  urine  passed,  it  is  most  important  to  show, 
by  percussion  or  catheterism,  that  there  is  urine  in  the  bladder,  and 
that  the  failure  of  micturition  is  not  due  to  suppression  of  urine.  We 
have  already  discussed  in  connection  with  abdominal  injuries  the 
apparent  anuria  which  occurs  in  laceration  of  the  bladder. 

(a)   Disturbances  of  the  Mechanism  of  Micturition. 

Retention,  due  to  disturbance  of  the  mechanism,  by  an  interrup- 
tion in  the  reflex  arc  or  by  cerebral  inhibition,  is  of  medical  rather 
than  of  surgical  interest.  The  surgeon  often  sees  this  form  of 
retention  after  operations,  due  to  psychical  inhibition. 

It  is  not  at  all  necessary  that  the  operation  should  be  on  the 
genitals,  urinary  tract  or  their  vicinity.  Retention  may  also  follow 
other  operations,  such  as  excision  of  a  goitre,  or  radical  cure  of 
hernia.  Sometimes  it  is  only  the  horizontal  posture  which  disturbs 
the  patient ;  in  other  cases  micturition  is  impossible  in  any  position. 
This  form  of  retention  may  be  compared  with  what  is  often  seen  in 
neurasthenics,  who,  for  instance,  are  quite  unable  to  micturate  in  the 
presence  of  another  person. 

The  retention  observed  in  semi-comatose  patients,  especially  in 
the  course  of  meningitis,  indicates  functional  disturbance  of  the  reflex 
process.  The  voluntary  retention  in  cases  of  painful  micturition 
previously  noted  is  quite  of  a  different  character.     In  cases  of  retention 


430      SURGICAL   DISEASES    OF   THE   ABDOMINAL   AND    PELVIC   VISCERA 

due  to  over-distension  of  the  bladder,  the  cause  is  paiiially  due 
to  disturbance  of  the  mechanism  of  micturition,  but  as  the  chief 
cause  is  some  mechanical  obstruction,  we  shall  discuss  this  type  of 
retention  in  the  latter  group. 

Anatomical  destruction  of  the  nerve  tracts  is  found  in  injuries  of 
the  spinal  cord,  and  in  compression  thereof  by  tubercular  caries  or 
tumours. 

(b)   Obstruction  of  the  Urethra. 

The  difficulty  caused  by  mechanical  obstruction  of  the  urethra 
has  much  greater  surgical  importance.  The  following  comprises  a 
summary  of  the  causes  of  such  obstruction  :  foreign  bodies  and 
stone,  inflammatory  and  traumatic  strictures,  compression  of  the 
urethra  from  without  by  a  haematoma,  tumour  or  inflammatory 
material,  &c.,  and  laceration  of  the  urethra.  Each  one  of  these  con- 
ditions possesses  its  own  peculiarities,  which,  as  a  rule,  render  the 
diagnosis  quite  easy. 

(a)  A  sudden  onset,  accompanied  by  pain  and  possibly  by  the 
passage  of  blood,  strongly  suggests  a  foreign  body  in  the  iiretJira.  It 
may  be  a  stone  from  the  bladder,  which  has  lodged  in  the  urethra^ 
a  very  probable  contingency  if  there  be  a  history  of  the  passage  of 
stones  or  of  discomfort  due  to  stones.  But  a  foreign  body  may  have 
been  introduced  from  without,  obstructing  the  urethra  either  by  its 
size  or  by  the  inflammation  which  it  provokes.  History  is  usually  silent 
in  these  cases,  and  nothing  less  than  the  ocular  demonstration  of  the 
foreign  body  suffices  to  extort  a  confession.  A  metal  catheter  and  a 
urethroscope  are  required  for  the  diagnosis.  The  extent  to  which 
sexual  perversion  may  go  is  shown  by  a  case  in  our  clinic,  wherein 
the  patient  filled  his  urethra,  as  far  as  the  sphincter,  with  plaster  of 
paris. 

Stones  may  remain  in  the  urethra  for  a  considerable  time  without 
leading  to  obstruction.  These  are  stones  lying  in  diverticula  and 
their  symptoms  are  of  a  chronic  nature. 

If  the  urethra  is  free,  the  cause  of  a  sudden  obstruction  must  be 
at  the  exit  from  the  bladder,  and  then  stone  at  the  vesical  neck  is 
most  probable.  In  certain  positions  such  a  stone  may  block  up  the 
neck  of  the  bladder  like  a  bail-valve.  In  most  of  these  cases  the 
patient  \\l\\  already  have  discovered  that  he  can  only  micturate  easily 
in  a  certain  posture  of  his  body.  Often,  the  micturition  will  be 
suddenly  interrupted,  or  the  previously  powerful  stream  becomes- 
suddenly  feeble. 

If  obstruction  has  apparently  come  on  suddenly  at  the  neck  of 
the  bladder,  and  it  remains  absolutely  unchanged  as  a  complete 
obstruction  for  a  day  or  more,  we  should  think  of  enlarged  prostate 
if  the  patient  is  an  elderly  man. 


GENERAL   REMARKS   ON    DISEASES   OF   THE   URINARY   ORGANS      431 

A  careful  inquiry  into  the  history  of  these  cases  will  elicit  the  fact 
that  there  have  been  symptoms  of  mild  obstruction  previously,  but 
that  the  patient  has  not  appreciated  their  importance.  The  sudden 
obstruction  is  also  partially  due  to  over-distension,  and  therefore  to 
disturbance  of  the  mechanism  of  micturition. 

(b)  Subacute  obstruction  of  tite  urethra  is  the  term  applied  to  those 
cases  wherein  the  process  develops,  without  any  warning,  in  the 
cours,e  of  a  few  days.  They  are  usually  caused  by  rapidly  growing 
swellings  which  press  on  the  urethra  from  without — in  males,  by 
abscesses  of  the  prostate  or  vesiculse  seminales,  or  peri-proctal 
suppuration  ;  in  females,  by  some  genital  tumour  strangulated  in 
the  true  pelvis  and  becoming  rapidly  larger  through  circulatory 
disturbances,  by  a  pregnant  retroflexed  uterus,  or  by  some  effusion 
under  high  pressure. 

(c)  Gradual  obstruction  of  tlic  urethra  presents  quite  a  different 
clinical  picture. 

The  patient  complains  that  for  weeks  or  months  he  has  had  to 
strain  during  micturition,  and  that  the  stream  does  not  reach  as  far  as 
formerly.  Attacks  of  catarrh  of  the  mucous  membrane  or  of  over- 
distension of  the  bladder  may  increase  the  symptoms  spasmodically, 
but  the  obstruction  may  become  complete  quite  suddenly,  and  its 
degree  never  varies,  as  it  does  in  cases  of  obstruction  by  stone. 

The  causes  of  this  gradual  obstruction  include  stricture,  new 
growth,  stone  in  a  urethral  diverticulum,  enlarged  prostate,  pelvic 
tumour,  or  a  very  chronic  abscess.  The  age  and  history  of  the 
patient  will  suggest  the  selection  from  these  causes,  and  local  examina- 
tion, which  we  shall  describe  later  on,  will  allow  us  to  make  a  more 
definite  diagnosis. 


(3)  DEFICIENT  CLOSURE  OF  THE  BLADDER. 

Inability  to  retain  the  urine,  incontinence,  may  be  due  to  many 
causes,  some  of  which  are  concerned  with  medicine,  others  with 
surgery. 

Disturbances  of  innervation  are  the  most  important  of  these  causes. 
They  may  be  of  a  purely  psychical  character  and  transitory  in 
nature  (fright  or  excitement).  In  other  cases  there  may  be  organic 
paralysis  of  the  sphincter,  in  which  condition  the  incontinence  is  not 
primary,  but  merely  the  result  of  retention  with  overflow,  from  an 
over-filled  bladder  (paradoxical  incontinence).  The  urine  dribbles 
away,  yet  the  bladder  may  reach  as  far  as  the  umbilicus.  Retention 
with  overflow  also  occurs  when  mechanical  obstruction  has  led  to 
over-distension  of  the  bladder,  e.g.,  in  enlarged  prostate. 

Incorrect  diagnosis  of  these  various  disturbances  is  quite  fre- 
quent.     Pure    incontinence    as    a    result    of    sphincter    paralysis    is 


432       SURGICAL   DISEASES   OF   THE   ABDOMINAL   AND   PELVIC   VISCERA 

confused  with  overflow  from  a  full  bladder  due  to  paralysis  of  the 
detrusor.  The  difference  is,  however,  very  obvious,  because  in  the 
former  case  the  bladder  is  emptv,  while  in  the  latter  it  is  full.  The 
constant  micturition  which  occurs  when  the  capacity  of  the  bladder 
is  very  small  (as  in  tuberculosis  or  stone)  is  sometimes  mistaken  for 
genuine  incontinence.  Finally,  pure  nervous  derangements  may  be 
regarded  as  the  result  of  mechanical  obstruction,  and  a  patient  with 
masked  tabes  diagnosed  as  a  case  of  enlarged  prostate.  These  mis- 
takes can  onl\^  be  avoided  by  a  complete  examination  of  the 
patient. 

Ulcerative  destruction   of  tJie  sphincter  by  new  growth  or  tubercle 
mav  also  lead  to  constant  flow  of  urine. 


(4)  VESICAL  TENESMUS 

must  not  be  confused  with  incontinence.  This  term  is  applied  to  all 
cases  wherein  there  is  increased  frequency  of  micturition,  accom- 
panied by  abnormal  sensation  of  irritation.  The  first  thing  which 
usually  strikes  the  patient  is  that  he  is  bound  to  get  up  once  or  more 
in  the  night,  although  he  has  not  taken  more  than  his  average 
allowance  of  liquid.  Then,  he  begins  to  be  annoyed  by  frequency 
of  micturition  during  the  day,  and,  finally,  strangury  sets  in,  which 
prevents  him  from   attending  to   his   occupation. 

The  bladder  is  in  a  constant  state  of  contraction  owing  to  some 
persistent  irritation.  It  is  unable  to  fill  up,  and  the  urine  escapes 
at  short  intervals,  although  the  sphincter  still  retains  the  full  powers 
of  closure.  The  main  cause  of  this  condition  is  cystitis,  especially 
of  tubercular  origin,  but  it  is  sometimes  due  to  a  large  stone  in  the 
bladder.  In  persons  with  extreme  reflex  irritability,  such  as  is  attri- 
buted to  Rousseau,  there  is  no  relation  between  the  physical  state  and 
the  degree  of  vesical  contraction.  Even  a  small  ulcer  ma}"  suffice  to 
produce  the  so-called  "irritable  bladder."  The  diagnosis  is  based 
on  the  frequency  of  micturition  and  the  diminution  of  the  capacity 
of  the  bladder,  which  can  be  demonstrated  by  the  injection  of  fluid. 

Whereas  a  normal  bladder  easily  holds  200  to  250  c.c,  an 
irritable  bladder  sometimes  rebels  against  one-tenth  of  this  quantity, 
and  it  is  often  quite  impossible  to  inject  the  80  to  100  c.c.  which 
are  required  for  cystoscopy,  at  any  rate,  without  the  aid  of  morphia 
or  anaesthesia. 

As  the  various  conditions  which  lead  to  the  anomalies  or  fre- 
quent micturition  are  very  liable  to  confusion,  they  may  be  briefly 
summarized  once  again  : — 

Anuria. — Absence  of  urinary  secretion,  or  its  retention  in  the 
kidneys  (the  former  in  severe  nephritis,  the  latter  in  stone  in  both 
kidneys)  ;    but  the  power  of  emptying  the  bladder  is   not  lost. 

Oliguria. — Very  small  amount  of  urine  secreted,  without  regard 
to  the  frequency  of  micturition  {e.g.,  in  nephritis,  ileus  and  diarrhoea). 


GENERAL   REMARKS   ON   DISEASES   OF   THE   URINARY   ORGANS        433 

Polyuria. — Increased  secretion  of  urine,  without  reference  to  the 
frequency  of  micturition   {e.g.,  in  diabetes). 

Pollakiuria. — Abnormalirequency  of  micturition,  without  reference 
to  the  quantity  of  urine.     This  may  be  the  result  of  : — 

{a)  Abnormal  filling  of  the  bladder,  with  incomplete  micturition 
(t'.^.,  enlarged  prostate). 

(6)  A  condition  of  abnormal  irritability  (vesical  tubercle,  vesical 
stone). 

(c)  An  abnormally  large  quantity  of  urine. 


5.— ABNORMAL   COMPOSITION    OF   THE    URINE. 

The  substances  which  a  patient  notices  as  abnormal  constituents 
of  his  urine  are  pus,  blood,  and  inorganic  deposits  in  the  form  of 
concretions. 

(1)   ADMIXTURE   WITH    PUS. 

The  naked  eye  should  never  be  relied  upon  for  the  diagnosis  of 
pus  ;  it  is  always  necessary  to  employ  chemical  examination  and  the 
microscope.  This,  however,  does  not  mean  that  the  naked  eye  cannot 
discover  a  good  deal  in  a  cloudy  urine. 

The  following  type  of  case  is  not  infrequent  :  A  patient  consults 
us  for  a  condition  which  has  been  diagnosed,  either  by  himself  or  by 
others,  as  cystitis.  He  complains  of  tenesmus,  and  in  evidence  of 
his  disease  he  puts  on  the  table  a  bottle  containing  whitish  cloudy 
urine.  While  describing  his  symptoms  in  full  detail,  a  sediment 
forms  in  the  bottle,  which  the  experienced  observer  sees  at  once  is 
not  pus,  but  carbonates  and  phosphates.  A  few  drops  of  acid  dissolve 
this  precipitate.  A  microscopic  examination  of  the  deposit  will 
reveal  amorphous  calcium  salts,  and  probably  also  the  beautiful 
crystals  of  di-calcium  phosphate  ;  sometimes  also  calcium  oxalate. 
A  few  general  directions  for  the  reghnen  of  the  body  and  mind  suffice 
to  cure  the  patient  of  his  "  cystitis." 

If  the  urine  is  slightly  cloudy,  but  forms  no  deposit  even  after 
long  standing,  nor  clears  up  on  the  addition  of  acid,  it  is  most 
probable  that  the  specimen  is  not  fresh,  but  has  become  a  culture 
medium  for  bacteria.  A  glance  with  the  microscope  shows  us  swarms 
of  bacteria  but  no  pus  cells.  If  the  patient  assures  us  that  the 
somewhat  cloudy  and  offensive  urine  has  been  passed  quite  recently, 
the  probability  is  that  the  bacterial  culture  has  developed  in  the 
urinary  passages,  and  another  examination  with  a  catheter  specimen 
would  prove  this.  Pus  cells  are  entirely  absent,  neither  are  there 
any  clinical  signs  of  inflammat-ory  disease  of  the  urinary  passages. 
The  case  is  one  of  "  bacilluria,"  generally  due  to  the  Bacillus  colt 
but  sometimes  to  the  typhoid  bacillus. 

If  there  really  be  pus  in  the  sediment,  the  urine  must  be  examined 
very  carefully  with  the  naked  eye.     If  gonorrhoeal  threads  or  small 


434      SURGICAL   DISEASES   OF   THE   ABDOMINAL   AND    PELVIC   VISCERA 

flakes  of  pus  float  about  in  it,  the  urethra  of  the  patient  must  be 
examined,  and,  according  to  circumstances,  the  urine  must  again  be 
investigated  after  washing  out  the  urethra,  or  the  three-flask  test  must 
be  undertaken.  If  the  pus  only  comes  from  the  anterior  urethra,  or 
from  the  posterior  urethra  as  well,  leaving  the  bladder  free,  the  case  is 
gonorrhoea.  If  both  the  urethra  and  the  bladder  discharge  pus,  we 
shall  rarely  err  if  we  diagnose  cystitis  as  a  complication  of  gonorrhoea. 
But  if  all  the  pus  comes  from  the  bladder,  we  must  inquire  whether 
there  is  always  a  sediment  in  the  urine,  or  whether  the  cloudiness  in 
the  specimen  under  examination  is  a  first  appearance,  or  whether  such 
cloudy  specimens  have  been  passed  on  previous  occasions.  If  the 
urine  is  uniformly  purulent,  or  at  any  rate  if  the  pus  contents  are  not 
subject  to  sudden  changes,  the  lesion  may  be  in  the  bladder,  although 
the  pus  may  come  from  the  pelvis  of  the  kidney. 

A  single  evacuation  of  very  purulent  urine,  or  of  pure  pus,  indicates, 
either  that  a  pyonephrosis  has  suddenly  emptied  into  the  bladder,  or 
that  a  perivesical  abscess  has  broken  into  it.  Such  an  abscess  may 
originate  in  the  appendix,  female  sexual  organs,  prostate,  or  pelvic 
bones.  This  event  will  always  have  been  preceded  by  symptoms 
which  permit  of  the  establishment  of  a  diagnosis.  The  appearance  of 
pus  in  the  urine  is  only  an  incident  in  the  course  of  the  underlying 
disease.     The  site  of  the  perforation  can  be  seen  with  the  cystoscope. 

We  now  proceed  to  the  clicinical  examination  of  the  urine.  The 
chief  information  which  this  affords,  apart  from  the  demonstration  of 
carbonates  and  phosphates  previously  mentioned,  concerns  the 
reaction  of  the  urine.  Diminution  of  acidity,  or  even  the  presence  of 
an  amphoteric  reaction,  has  no  serious  significance,  as  long  as  the 
urine  is  odourless,  and  if  any  cloudiness  which  may  be  present 
disappears  on  the  addition  of  acid.  On  the  other  hand,  a  diminution 
of  acidity  in  pus-containing  urine,  and  the  presence  of  an  alkaline 
reaction,  indicates  secondary  infection  of  the  urinary  passages  by 
organisms  like  the  staphylococci  and  Proteus  vulgaris,  which 
decompose  urea.  The  latter  causes,  in  addition  to  an  alkaline  reaction 
ammoniacal  fermentation,  which  betrays  itself  at  once  by  the  smell. 
If  pus-containing  urine  is  acid,  but  does  not  smell  offensively,  the 
condition  is  usually  tubercular  or  one  of  streptococcal  infection.  If 
it  is  acid  and  offensive  in  smell,  the  Bacillus  coli,  and  probably  other 
inflammatory  organisms,  are  responsible. 

It  goes  without  saying  that  the  chemical  examination  of  the  urine 
must  always  include  tests  for  albumin  and  sugar,  and  for  biliary  and 
blood  pigment  when  necessary. 

The  most  important  part  of  the  microscopic  investigation  of  the  urine 
concerns  the  various  forms  of  cells.  If  polynuclear  leucocytes  pre- 
ponderate,   the    morbid    process    is  an  acute    one  ;    if   mononuclears 


GENERAL   REMARKS    OX   DISEASES    OF   THE    URINARY   ORGANS      435 

preponderate  we  should  rather  think  of  tuberculosis.  Bladder 
epithelium  indicates  the  presence  of  ulcers,  especially  if  it  is  found  in 
shreds,  and  if  specimens  of  the  deeper  layers  occur  (caudate  epithelium). 
Red  blood  corpuscles  point  to  the  same  conclusion.  Whenever  pus 
cells  are  present,  cylindrical  cells  should  always  be  sought  for. 

It  is  then  necessary  to  note  the  presence  of  various  kinds  of  uiicro- 
organisms.  The  demonstration  of  tubercle  bacilli  possesses  a  special 
significance,  and  to  prevent  their  confusion  with  smegma  bacilli,  a 
catheter  specimen  must  be  obtained,  a  precaution  requisite  in  all 
bacteriological  investigations  of  urine.  If  nothing  is  found,  this  is 
naturally  no  evidence  against  tuberculosis.  But  we  must  not  hastily 
conclude  that  the  suppuration  has  been  adequately  explained  by  the 
discovery  of  the  Bacillus  coli,  staphylococci  or  streptococci.  These 
organisms  may  certainly  exist  independently,  but  they  often  accompany 
the  tubercle  bacillus,  even  in  uncatheterized  cases,  and  may  indeed 
completely  overshadow  it  in  the  urine.  We  may  even  go  a  step 
further  and  say  that  every  case,  wherein  these  organisms  persistently 
occur  in  the  urine,  is  very  suspicious  of  tubercle.  The  suspicion  is 
even  greater,  if  only  pus  cells  are  found  and  no  micro-organisms  at 
all.  Such  cases  are  almost  always  tubercular.  This  diagnosis  is 
obviously  arrived  at  by  a  process  of  exclusion,  but  it  can  be  confirmed 
by  the  inoculation  of  guinea-pigs — a  procedure  which  should  never  be 
neglected  if  tubercle  bacilli  are  not  found  in  the  direct  examination  of 
purulent  urine,  in  cases  wherein  there  is  no  other  cause  for  the 
suppuration.  If  this  experiment,  conducted  with  an  adequate  amount 
of  sediment,  yields  no  result,  we  are  then  justified  in  assuming  that 
the  case  is  one  of  pyelitis  due  solely  to  the  "  ordinary"  pus  organisms. 
Experience,  however,  shows  that  such  cases  are  really  of  quite  unusual 
occurrence. 

(2j  ADMIXTURE    WITH    BLOOD. 

The  presence  of  blood  in  the  urine  is  always  a  serious  matter, 
whether  there  are  only  a  few  red  cells  detected  by  the  microscope,  or 
whether  there  has  been  profuse  haemorrhage. 

(i)  If  the  blood  is  quite  red  and  also  flows  independently  of 
micturition,  it  comes  from  the  urethra  and  must  be  ascribed  to  injury, 
possibly  by  a  foreign  body. 

Smaller  periodical  h?emorrhages  independently  of  micturition 
indicate  some  ulcerative  process  in  the  urethra  (cancer,  or  stone  in 
a  diverticulum).  The  appearance  of  hloocUstaincd  semen  should  also  be 
mentioned.  Cases  occur  wherein  there  is  a  discharge  of  blood-stained 
semen,  quite  apart  from  any  sexual  activitv,  and  even  after  the  period 
of  sexual  life  has  been  left  behind,  although  no  objective  demonstrable 
disease  of  the  sexual  organs  be  present. 


436      SURGICAL   DISEASES   OF   THE   ABDOMINAL   AND    PELVIC    VISCERA 

(2)  If  the  blood  is  mixed  with  the  urine  and  appears  only  with 
micturition,  it  must  come  from  the  ,  bladder,  ureter  or  kidneys. 
Attempts  have  been  made  to  decide  whether  the  blood  comes  from 
the  kidneys  or  the  bladder,  on  the  basis  of  the  more  or  less  pro- 
nounced change  in  the  colour  of  the  blood.  These  are,  however, 
unreliable,  because  everything  depends  on  the  rapidity  of  the  haemorr- 
hage, the  amount  of  blood  and  the  duration  of  the  contact  between 
the  urine  and  the  blood.  If  the  haemorrhage  in  the  bladder  is  slight, 
and  the  blood  remains  within  it  for  any  considerable  time,  it  under- 
goes the  same  changes  as  occur  in  haemorrhage  in  the  pelvis  of  the 
kidney.  Much  more  reliable  conclusions  may  be  derived  from  the 
associated  symptoms.  If  the  haemorrhage  is  attended  by  vesical  colic 
— due  to  the  expulsion  of  coagula — and  by  no  other  symptom,  the 
blood  most  probably  comes  from  the  bladder.  If  renal  colic  is  present, 
its  origin  is  in  the  kidneys.  If  there  be  no  pain,  nor  any  indications  of 
tumour  in  the  bladder  or  kidney,  we  may  be  able  to  obtain  some 
information  by  examining  the  urine  after  massage  of  the  kidneys. 
The  last  stage  of  the  examination  consists  of  cystoscopy. 

(3)  If  there  be  pus  in  the  bloody  urine,  or  in  the  urine  of  the 
intervals  wherein  it  is  free  from  blood,  we  should  think  especially  of 
tubercle,  or  of  some  vesical  or  renal  disease  with  secondary  infection, 
however  slight  the  traces  of  pus  may  be. 

(4)  Microscopic  traces  of  blood,  constantly  found  in  the  sediment 
or  the  centrifugalized  portion,  indicate  either  stone  or  tuberculosis. 

(5)  Intermittent  haemorrhage  and  the  presence  of  cylindrical  cells 
and  albumin  in  the  intervals  when  the  urine  is  free  from  blood,  are 
signs  of  chronic  haemorrhagic  nephritis. 

Nephritis  may,  however,  occur  without  albumin  and  without 
cylindrical  cells,  as  shown  by  Rovsing.  But  we  should  only  conjecture 
such  a  diagnosis  in  cases  wherein  the  blood  comes  from  both  sides 
and  cannot  otherwise  be  explamed. 

It  is  also  necessary  to  add,  for  the  sake  of  completion,  that  renal 
haemorrhage  may  occur  in  haemophilia  and  in  transitory  ha3morrhagic 
diatheses,  as  in  purpura.  Whether,  apart  from  the  above-mentioned 
conditions,  bleeding  may  occur  from  healthy  kidneys — idiopathic  renal 
haemorrhage — as  is  often  assumed,  must  be  left  an  open  question. 
Such  a  diagnosis  can  only  be  made  with  certainty /)os^  mortem,  because 
anatomical  changes  cannot  be  excluded  unless  histological  examination 
of  both  kidneys  has  been  undertaken. 

(3)  ADMIXTURE    WITH     INORGANIC     DEPOSITS    OR    CON- 
CRETIONS.    (URINARY    GRAVEL.) 

Inorganic  sediment  is  the  third  form  of  urinary  admixture 
which  worries  the  patient  and  impels  him  to  seek  advice.  This  sedi- 
ment varies  from  a  flocculent  deposit  of  microscopic  particles  and 


GENERAL   REMARKS   ON   DISEASES   OF   THE   URINARY   ORGANS       437 

crystals,  to  the  size  of  a  pea,  e.g.,  to  a  calibre  which  can  just  pass 
through  the  urethra.  We  have  already  referred  to  sediment  composed 
of  carbonates,  phosphates  and  oxalates.  In  the  case  of  "gravel"  or 
larger  concretions  the  diagnosis  of  calculous  disease  is  obvious.  Bot 
such  a  diagnosis  should  not  satisfy  us.  It  is  much  more  important  to 
decide  whether  we  are  dealing  with  an  ''  aseptic  "  or  with  an  "  infected  " 
case.  In  the  former,  the  urine  is  free  from  pus  and  the  concretions 
consist  of  calcium  oxalate,  uric  acid,  urates  and  occasionally  of  cystin. 
In  the  latter,  the  urine  is  purulent  and  the  concretions  consist, 
exclusively  or  largely,  of  ammonium-magnesium  phosphate  and  basic 
calcium  phosphate. 


(U 

,,         -J    .    ,    f  With  ammonia — purple  red 
Murexide  test  -^  with  ^dausUc  potash-purple  violet 

Uric  Acid 
Urates 

s 

,,         -j^^i  With  ammonia — yellow 
Murexide  test  |  ^^.^^  ^^^,^^j^  potash-orange 

Xanthin 

U 

The  powder  burns  with  a  slightly  luminous  blue  flame,  and 
smells  like  burning  sulphur  and  oil  of  asafoetida 

Cystin 

IS 

The  powder  effervesces  with  hydrochloric  acid 

Calcium  Carbonate 

.0 

s 

0 
u 
c 
I— 1 

The  powder  does  not 
effervesce  with    hydro- 
chloric acid 

but  does  so  after  heating  to  redness 

Calcium  Oxalate 

and    does   not   do   so,    even   after 
heating  to  redness 

Earthy  Phosphate 

The  diagnosis  can  often  be  made  from  the  microscopical  examina- 
tion, because  the  urine  frequently  contains,  in  addition  to  the  peculiar 
granules  of  gravel,  some  crystals  of  the  corresponding  salts,  illustra- 
tions of  which  are  given  in  any  text-book  of  clinical  methods.  If 
these  crystals  are,  however,  absent,  the  diagnosis  can  be  made  by  the 
experienced  observer  without  any  difficulty,  from  the  above  scheme 
suggested  by  Ultzmann. 

The  origin  of  these  concretions  cannot  be  determined  forthwith, 
at  any  rate  not  of  all  of  them.  We  may,  however,  assume  that 
clinically  aseptic  concretions  originate  in  the  renal  pelvis,  while 
secondary  stones  may  form  either  in  the  renal  pelvis  or  the  bladder. 
Gravel  might  come  from  either  source,  but  small  facetted  burnished 
stones  usually  originate  in  the  renal  pelvis. 


C— LOCAL  SYMPTOMS. 

An  accurate  diagnosis  can  only  be  made  after  the  direct  examina- 
tion of  the  organs  concerned.  We  shall  later  on  discuss  the  various 
groups  of  disease  in  detail,  but  for  the  present,  will  limit  ourselves  to  a 


438      SURGICAL   DISEASES    OF   THE   ABDOMINAL   AXD   PELVIC    VISCERA 

few  remarks  on  the  method  of  examination,  and  the  so-called ////?r//o//c7/ 
diagnosis  of  renal  disease. 

The  patient  must  first  pass  a  portion  of  his  urine — if  he  can — and 
we  put  this  aside  for  a  careful  examination,  particularly  to  ascertain 
whether  there  is  any  admixture  with  blood.  The  character  of  the 
stream  and  the  naked-eye  appearance  of  the  urine  will  already  have 
furnished  important  information  (gonorrhoeal  threads,  pus,  gravel). 
We  then  feel  the  urethra,  lest  we  miss  some  foreign  body,  tumour, 
or  scar  tissue  which  may  be  felt  from  the  outside,  and  afterwards 
we  palpate  over  the  bladder  and  kidneys.  A  wide  Nelaton  catheter  is 
then  introduced,  having  previously  satisfied  ourselves  as  to  the  con- 
dition of  the  instrument. 

It  is  very  unfortunate  if  the  practitioner  has  to  extract  a  broken 
piece  of  catheter  himself,  or  obtain  the  services  of  some  one  else  to 
do  it  for  him. 

The  following  are  the  usual  possibilities: — 

(i)  If  the  catheter  enters  the  bladder  easily,  although  the  patient 
cannot  himself  micturate,  the  neck  of  the  bladder  must  be  obstructed 
by  a  stone,  foreign  body,  or  tumour ;  or  it  may  be  a  case  of  enlarged 
prostate,  or  compression  of  the  urethra  from  without — assuming,  of 
course,  that  a  nervous  derangement  is  not  in  question.  In  cases  of 
enlarged  prostate  or  external  compression  of  the  urethra,  the  catheter 
experiences  some  little  difficulty  when  it  reaches  the  pars  prostatica. 
We  then  take  a  medium-sized  metal  catheter  of  the  ordinary  curve,  and 
introduce  it  very  carefully.  If  we  reach  the  bladder  after  impinging 
on  a  hard,  rough  substance,  there  can  be  no  doubt  about  the  diagnosis 
of  stone  or  foreign  body.  If  nothing  is  felt,  we  must  notice  whether 
it  is  necessary  to  depress  the  eye  of  the  catheter  very  much  before  the 
urine  flows.  In  this  event  the  pars  prostatica  is  lengthened,  which 
means  that  an  enlarged  prostate  is  probably  present.  Sometimes  it  is 
necessary  to  elevate  the  patient's  pelvis  in  order  to  depress  the 
catheter  sufficiently.  The  diagnosis  obtains  further  confirmation  if 
we  cannot  empty  the  bladder  with  the  ordinary  shaped  catheter,  but 
succeed  in  doing  so  with  a  semi-circularly  curved  tin  catheter,  or 
with  an  elastic  catheter  with  Mercier's  curve. 

Having  succeeded  in  introducing  into  the  bladder  a  medium-sized 
or  wide  catheter,  either  with  or  without  this  special  manoeuvre,  the 
c]uestion  arises  as  to  whether  we  are  dealing  with  a  simple  prostatic 
hypertrophy,  a  prostatic  tumour,  or  with  some  pathological  structure 
in  the  vicinity,  which  is  pressing  on  the  urethra.  The  latter  usually 
signifies  a  swelling,  which  is  more  often  malignant  than  innocent,  and 
includes  tumours  of  the  pelvic  bones  and  connective  tissue,  such  as 
sarcomata,  chondromata,  osteomata,  and  cysts,  mainly  dermoids. 
The  distinction  between  these  conditions  and  enlarged  prostate  is 
made  by  rectal  and  combined  recto-abdominal  examination. 


GENERAL    REMARKS    OX    DISEASES    OF   THE    URINARY   ORGANS        439 

With  the  finger  introduced  into  the  rectum,  we  first  feel  the 
anterior  wall  of  the  ampulla,  and  follow  the  outlines  of  the  prostate 
with  tiie  finger  tip.  It  is  impossible  to  learn  from  books  what  this 
feels  like  ;  it  must  be  studied  on  the  living  subject.  If  the  mucous 
membrane  is  soft  and  cedematous,  with  the  prostate  enlarged  and 
rather  elastic,  feeling  like  a  pillow,  and  at  the  same  time  tender  to  pres- 
sure, the  case  is  one  of  acute  prostatitis  or  of  prostatic  abscess.  If  the 
swelling  is  higher  up,  the  case  is  one  of  inflamed  vesiculae  seminales. 

If  the  prostate  is  enlarged,  but  not  painful  on  pressure,  the  case  is 
one  of  enlarged  prostate,  cancer,  or  sarcoma.  If  there  is  nothing 
special  found  in  the  prostate,  the  hypertrophy  may  be  in  the  direction 
of  the  bladder  with  or  without  a  middle  lobe,  or  the  prostate  may  be 
in  a  state  of  diffuse  sclerosis,  or  there  may  even  be  a  contracting 
cancer  present.     (See  further  Chapter  LXIX,). 

Otherwise  there  must  be  present  one  of  the  previously  mentioned 
tumours,  pressing  on  the  neck  of  the  bladder  from  without.  (See 
Chapter  LXXIII.). 

In  the  female  sex,  in  addition  to  the  pressure  of  the  foetal  head 
during  labour,  it  is  necessary  to  mention  uterine  tumours  incarcerated 
in  the  true  pelvis,  as  well  as  retroflexion  of  the  gravid  uterus.  Every- 
one of  experience  knows  those  tumours,  reaching  as  high  as  umbilicus,^ 
which  beginners  look  upon  as  ovarian  cysts,  but  which  disappear  as 
soon  as  a  catheter  is  passed.  It  is  most  important  to  make  an  accurate 
estimate  of  the  state  of  affairs,  as  a  very  prolonged  over-distension 
may  result  in  complete  sloughing  of  the  mucous  membrane  of  the 
bladder.  A  similar  result  may  occur  from  rapidly  growing  tumours, 
strangulated  within  the  true  pelvis,  as  I  have  seen  in  a  case  of  sarcoma 
of  the  uterus. 

(2)  If  a  medium-sized  catheter  does  not  enter  the  bladder,  but  a 
narrow  one  does,  a  stricture  is  present.  If  it  is  not  very  definite,  it  is 
useful  to  employ  Guyon's  olivary  bougie,  because  we  are  better  able 
to  appreciate  the  obstruction  with  this  instrument  than  with  a 
cylindrical  or  a  cylindro-conical  catheter.  But  if  even  the  smallest 
catheter  will  not  enter,  we  must  try  a  series  of  elastic  bougies  of  the 
calibre  of  catgut,  putting  in  one  after  the  other.  A  path  will  some- 
times be  found  in  this  manner.  The  cause  of  the  stricture  is  either 
gonorrhoea  or  new  growth.  If  the  age  and  history  of  the  patient, 
and  slight  haemorrhage  from  the  stricture  suggest  cancer  of  the 
urethra,  it  may  be  possible  to  establish  this  diagnosis  by  palpating 
the  urethra  and  the  use  of  the  urethroscope. 

(3)  If  no  instrument  at  all  passes,  the  case  is  a  severe  example  of 
one  of  the  two  above-mentioned  classes.  If  the  age,  sex,  and  external 
circumstances  do  not  give  a  clue,  and  if  the  over-filled  bladder 
prevents  a  satisfactory  examination,  we  must  puncture  the  bladder  as  a 


440      SURGICAL   DISEASES    OF   THE   ABDOMINAL   AND    PELVIC   VISCERA 


matter  of  urgency,  and  then  provide  an  exit  as  rapidly  as  possible,  either 
above  or  below,  in  accordance  with  the  physical  condition  found. 


(a)  Unilateral  inhibition  of 
the  renal  function  (trauma,  in- 
farct). Local  sj-mptoms.  No 
marked  disturbance  of  urinary 
excretion  (function  taken  on 
by  other  kidney). 


(a  +  a'')  Bilateral  inhibi- 
tion of  the  renal  functions 
(nephritis).  Anuria.  Bladder 
empty.     Death  from  uremia. 

(fi)  Unilateral  obstruction 
of  renal  pelvis  (kinking  owing 
to  abnormal  insertion,  or 
floating  kidney,  blocking  by 
stone).  Unilateral  renal  colic. 
Hydronephrosis.  No  uraemia. 


(i  +  31)  Bilateral  obstruc- 
tion of  renal  pelves  (most  fre- 
quently stone).  Bilateral 
renal  colic,  anuria,  uraemia. 


(3  -f  ffll)  Obstruction  by 
stone,  with  reflex  anuria. 
Same  symptoms,  but  colic 
only  unilateral. 


(c)  Blocking  of  one  ureter. 
(Stone,  pressure  by  tumours). 
Same  symptoms  as  in  ^. 


a^  =  a 


-  ^1. 


(d)  Obstruction  of  neck  of 
bladder  by  stone.  Retention 
of  urine.  Bladder  distended. 
Flow  of  urine  variable. 
Catheterism  easy. 


(e)  Neck  of  bladder  ob- 
structed by  tumour.  (En- 
larged prostate,  cancer,  sar- 
coma.) Retention  of  urine, 
partial  (residual  urine)  or 
complete.  Large  catheter 
usually  passes  easily. 


(/)  Obstruction  by  urethral 
stricture.  (Trauma,  gonorr- 
hoea). Retention  of  urine. 
Only  a  small  catheter  can  be 
passed,  but  this  sometimes 
fails. 


^ 


Fig.  201. — Diagram  of  the  various  surgical  derangements  of  micturition. 

(4)  If  the  bladder  is  easily  accessible,  and  it  is  necessary  to  decide 
the  nature  of  the  vesical  disease,  or  the  source  of  blood  or  pus,  we 
must  employ  the  aid  of  the  cystoscope. 


GENERAL   REMARKS    OX   DISEASES    OF   THE   URINARY   ORGANS       441 

This  instrument  shows  us  whether  the  mucous  membrane  is 
healthy,  inflamed,  covered  with  tibrin,  or  ulcerated.  It  also  shows 
us  the  position  of  ulcers  which  may  be  present,  and  if  they  are 
arranged  around  one  ureteral  orifice,  it  indicates  to  us  which  kidnev 
is  diseased.  It  also  shows  us  the  shape  of  the  ureteral  orifices,  it 
tells  us  whether  the  wall  of  the  ureter  is  thickened,  and  enables  us  to 
decide  the  character  of  the  urine,  which  trickles  at  intervals  from  the 
ureteral  orifice,  in  accordance  with  its  transparency  or  cloudiness. 
By  its  means  we  are  also  able  to  see  stones,  foreign  bodies, 
tumours,  and  diverticula.  But  it  is  indispensable  that  the  bladder 
should  be  able  to  hold  80  c.c.  of  water,  and  that  there  should  not  be 
any  severe  lijcmorrhage. 

The  technique  of  the  examination  is  not  described  here,  because 
the  general  practitioner  cannot  be  expected  to  do  more  than  have  the 
examination  carried  out  early  enough  for  the  successful  issue  of  any 
surgical  operation  which  may  be  necessary. 

If,  finally,  we  have  to  determine  the  functional  capacity  of  the 
whole  renal  apparatus,  or  of  each  individual  kidney,  this  is  a  matter 
of  the  so-called  functional  diagnosis  of  renal  activity.  This  does 
not  come  within  the  province  of  the  general  practitioner,  because  it 
requires  more  technical  practice,  experience,  and  time  than  he  has  at 
his  disposal.  He  will,  however,  desire  to  know  how  it  is  carried  out, 
and  what  results  it  yields. 

The  functional  activity  of  the  total  renal  parenchyma  is  first 
estimated,  and  then  that  of  each  individual  kidney. 

The  first  task  demands  the  estimation  of  the  freezing  point  of  the 
blood,  according  to  Koranyi.  The  lower  this  is,  the  more  *' urinary" 
substances  there  are  in  the  blood,  and  the  functional  activit}^  of  the 
total  renal  apparatus  is  correspondingly  unsatisfactory.  The  normal 
freezing  point  is  o'59,  but  the  lower  limit  of  0*56  is  allowed.  There 
are  many  sources  of  error  in  the  method,  but  in  some  cases  it  is  useful. 
Important  information  may  be  derived  from  the  estimation  of  the 
amount  of  urea  passed  in  a  day  on  a  definite  diet,  and  by  testing  the 
permeability  of  the  kidneys  to  water  and  to  sodium  chloride. 

The  solution  of  the  second  problem  demands  the  separation  of  the 
products  of  the  two  kidneys,  by  means  of  an  intra-vesical  partition  or 
by  catheterizing  the  ureters.  The  activity  of  each  kidney  is  then  tested 
by  determining  the  freezing  point  of  the  urine,  by  estimating  the 
nitrogen,  or  by  examining  the  reaction  of  the  kidneys  towards  certain 
subcutaneous  injections.  Thus  the  time  which  it  takes  for  a  gluteal 
injection  of  indigo  carmine  (4  c.c.  of  a  4  per  cent,  sterile  solution)  to 
appear  in  the  urine  is  estimated  (normal  time  ten  to  fifteen  minutes). 
Or  a  subcutaneous  injection  of  "005  grm.  of  phloridzin  is  given  and  the 
amount  of  sugar  excreted  by  one  kidney  in  a  definite  time  is  measured  ; 
or  one  notes  accurately  w^hen  the  excretion  begins.  None  of  these 
methods  as  hitherto  emplo^'ed  are  quite  free  from  objection,  but  the 
sum  total  of  the  conclusions  which  they  yield  may  be  of  distinctive 
significance  from  the  point  of  view  of  diagnosis  and  treatment. 


442     SURGICAL  diseasp:s  of  the  abdominal  and  pelvic  viscera 


CHAPTER  LX. 

INFLAMMATION     IN     THE     NEIGHBOURHOOD    OF 

THE  KIDNEY. 

It  is  necessary  to  begin  with  a  word  about  nomenclature.  An 
attempt  has  been  made  to  distinguish  betw^een  paranephritis  and  peri- 
nephritis, w^hich  were  previously  considered  synonymous.  It  has 
been  suggested  to  limit  the  term  perinephritis  to  inflammation  of  the 
connective  tissue  capsule  of  the  kidney,  and  paranephritis  to  suppura- 
tion within  the  fatty  covering.  Further,  Israel  has  designated  the 
inflammation  which  occurs  exclusively  between  the  kidney  and  retro- 
renal  fascia  as  epiiiephritis.  However  logical  these  distinctions  may 
be,  they  cannot  be  applied  in  actual  practice,  because  these  three 
different  anatomico-pathological  conditions  do  not  present  separate 
clinical  pictures.  Perinephritis,  defined  as  above,  is  never  a  disease 
by  itself,  but  is  ahvays  an  accompanying  symptom,  and  has  neither 
diagnostic  nor  clinical  significance.  It  is  almost  impossible,  clinically, 
to  suspect  any  distinction  between  paranephritis  and  epinephritis. 
Such  a  distinction  is  only  possible  at  the  operation  or  the  autopsy, 
and  it  really  possesses  no  practical  significance.  We  therefore  will 
adhere  to  the  term  perinephritis  as  implying  all  inflammation  between 
the  kidneys,  peritoneum  and  lumbar  muscles — a  uniformity  of  nomen- 
clature which  should  obtain  international  sanction. 

There  are  three  stages  of  perinephritis,  each  of  which  gives  rise  to  a 
special  train  of  diagnostic  considerations. 

(i)  The  indications  which  should  suggest  a  perirenal  abscess  are 
somewhat  similar  to  those  which  suggest  a  subphrenic  abscess.  The 
patient  becomes  ill  with  high  fever  and  obscure  symptoms,  which  he 
attributes  to  some  malady  in  the  loin,  because  that  region  is  painful. 
If  the  lumbar  spine  is  rigid,  and  probably  also  held  obliquely,  the 
suspicion  of  perirenal  abscess  is  confirmed,  and  the  condition  of  the 
lumbar  muscles  must  be  investigated.  If  they  are  contracted  on  one 
side,  or  if  they  contract  on  being  palpated,  we  are  in  all  probability 
within  reach  of  the  site  of  the  disease. 

In  this  stage  the  most  frequent  error  arises  from  confusion  with 
pleurisy.  In  the  latter,  however,  the  pains  radiate  towards  the  shoulder, 
whereas  in  perinephritis  they  radiate  towards  the  half  of  the  abdomen 
on  the  affected  side,  towards  the  external  genitals  and  even  as  far  as 
the  thigh. 

I  have  had  a  case  wherein  definite  lumbar  pain  which  radiated 
downward  caused  me  to  expose  the  kidney,  whereas  the  real  trouble 
was  a  commencing  empyema  which,  however,  afforded  no  clear  local 
symptoms.  The  difficulty  in  diagnosis  would  be  much  greater  if  a 
purulent  pleurisy  supervened  on  an  early  perinephritis.  The  result 
obtained  by  an  exploratory  puncture  is  attended  by  the  same  difficulty 
of  interpretation  as  occurs  in  cases  of  subphrenic  abscess. 


INFLAMMATIOX    IN    THE    NEIGHBOURHOOD    OF   THE    KIDNEY  443 

(2)  In  the  second  stage  the  diagnosis  is  much  easier,  because,  in 
addition  to  the  above  symptoms,  a  resistance  can  be  felt  in  the  lumbar 
region.  If  this  resistance  is  sharply  defined,  and  round  in  contour, 
the  inflammation  is  usually  in  the  kidney  itself.  If  it  is  diffuse  and 
indefinite,  the  perirenal  tissue  is  involved,  although,  of  course,  the 
kidney  itself  may  also  be  affected.  If  we  are  doubtful  about  the 
definition  of  the  swelling,  because  it  appears  to  be  too  sharply  defined 
for  a  phlegmon,  and  insufficiently  defined  for  a  kidney,  we  must  note 
whether  the  swelling  moves  on  respiration.  A  kidney  always  moves 
downwards  on  deep  respiration,  even  if  it  is  morbidly  enlarged, 
provided  there  are  no  perirenal  changes.  A  perirenal  abscess  remains 
immovable. 

Sharply  defined  abscesses  are  otherwise  generally  of  a  tubercular 
nature,  and  are  recognized  by  the  slight  pain  which  they  cause  on 
pressure  and  by  the  very  moderate  effect  which  they  have  on  the 
temperature  of  the  body. 

(3)  In  the  third  stage,  the  abscess  may  open  into  the  lumbar 
region,  causing  a  subcutaneous  phlegmon,  or  it  may  travel  into  the 
pelvic  fossa,  provoking  flexion  of  the  thigh,  or,  finally,  it  may  reach 
the  pleural  cavity,  and  burst  into  a  bronchus.  In  all  these  conditions, 
the  diagnosis  of  abscess  can  hardly  be  mistaken,  but  its  original  source 
in  such  advanced  cases  can  only  be  ascertained  from  the  history. 

We  should  not,  in  any  case,  be  content  with  the  diagnosis  of 
psoas  abscess,  which  used  to  be  a  very  favourite  one.  Psoas  abscess 
inay  be  a  tubercular  burrowing  abscess,  an  osteo-myelitic  suppuration, 
inflammation  arising  from  the  kidney  or  intestine  invading  the 
muscle,  or,  finally,  a  phlegmon  which  has  originated  in  the  broad 
ligament  ;  a  psoas  abscess  never  constitutes  a  disease  of  itself. 

So  far,  our  diagnosis  has  been  directed  to  suppuration  in  the  peri- 
renal fatty  tissue.  We  look  for  its  origin  particularly  in  the  kidney, 
pelvis,  or  spinal  column.  But  its  source  may  also  be  in  one  of  the 
intraperitoneal  viscera — appendix,  liver,  gall-bladder  or  large  intestine. 

If  the  urine  contain  pus,  we  must  refer  the  perinephritis  to  renal 
tuberculosis,  nephrolithiasis  or  some  other  kidney  disease  attended  by 
suppuration.  If  the  history  does  not  point  to  any  previous  kidney 
trouble,  we  should  think  of  some  acute  metastatic  renal  abscess,  and 
search  for  a  primary  source  of  infection,  e.g.,  a  fuiuncle,  sore  throat  or 
eczema.  In  other  cases  the  primary  disease  is  some  infectious  disorder, 
such  as  typhoid  fever,  small-pox,  &c.  If  nothing  abnormal  is  found 
in  the  urine,  this  is  not  to  be  regarded  as  conclusive  against  a  renal 
origin.  If,  despite  the  absence  of  any  abnormality  in  the  urine,  there 
is  a  history  of  some  old-standing  renal  disease,  we  must  assume  that 
the  ureter  on  the  affected  side  is  blocked  up. 

If  there  be  no  evidence  whatsoever  pointing  to  the  kidneys,  we 
must  examine  the  adjacent  bony  parts,  not  only  when  the  abscess  is 
29 


444      SURGICAL   DISEASES   OF   THE   ABDOMINAL   AND   PELVIC    VISCERA 

chronic  and  bears  tubercular  characteristics,  but  also  when  the  abscess 
lias  developed  acutely,  because  this  may  be  due  to  osteo-myelitis  of 
the  pelvis.  Should  nothing  be  elicited  here,  we  must  next  think  of 
the  appendix,  which,  not  infrequently,  lies  in  a  lumbar  or  even  a  pre- 
renal position.  In  such  cases  we  cannot  attain  to  anything  more  than 
a  probable  diagnosis,  unless  the  appendix  had  originally  been  intra- 
peritoneal and  given  rise  to  typical  attacks  of  appendicitis. 

There  is  no  difficulty  in  diagnosis  in  the  cases  wherein  a  phleg- 
monous parametritis,  following  an  abortion  or  confinement,  has 
extended  as  far  as  the  lumbar  region.  Liver  and  gall-bladder  abscesses 
rarely  encroach  upon  the  perirenal  tissue,  but  such  secondary 
abscesses  are  recognizable  by  their  history  and  the  localization  of  the 
antecedent  inflammatory  symptoms. 

If  no  other  cause  whatsoever  can  be  discovered,  we  may  assume 
that  the  case  is  a  primary  perinephritis,  i.e.,  an  infection  of  perirenal 
tissue  by  micro-organisms  of  unknown  origin,  and  without  any 
demonstrable  involvement  of  the  renal  tissue.  These  abscesses  usually 
arise  through  the  coalescence  of  small  abscesses  of  the  renal  cortex, 
which  cause  no  symptoms  in  themselves,  and  do  not  alter  the 
character  of  the  urine. 


CHAPTER  LXI. 
MOVABLE  KIDNEY. 

At  one  time  movable  kidneys  were  very  fashionable,  and  to  undergo 
treatment  for  them  was  regarded  as  an  evidence  of  good  tone;  but 
this  is  now  a  thing  of  the  past.  We  are  now  better  able  to  realize  the 
significance  of  this  condition  than  we  were  fifteen  years  ago,  and 
although  movable  kidneys  have  been  unjustifiably  condemned  for  all 
kinds  of  ills,  nevertheless  they  do  raise  important  problems  of  diagnosis, 
which  should  be  considered  together. 

Firstly,  as  to  the  evidence  of  their  existence. 

The  term  should  only  be  applied  to  kidneys  which  have  acqnircd 
increased  mobility,  and  not  to  those  which  are  the  subject  of  congenital 
displacement — a  matter  already  discussed.  This  acquired  mobihty 
may,  however,  often  be  due  to  congenital  causes.  Thus  I  have 
seen  a  movable  kidney  in  a  young  girl,  aged  ii,  who  was  otherwise  in 
perfect  health — an  abnormality  which  was  most  probably  the  result  of 
some  congenital  predisposition. 


MOVABLE    KIDNEY 


445 


The  following  method  should  be  adopted  to  demonstrate  a  movable 
kidney.  The  patient — usually  a  female — must  lie  f]at  and  as  relaxed  as 
possible.  The  lumbar  muscles  must  be  supported  with  one  hand,  but 
they  must  not  be  allowed  to  become  tense  ;  the  other  hand  is  gently 
pressed  under  the  costal  margin  against  the  spinal  column,  but  care 
must  be  taken  not  to  make  the  muscles  contract.  The  patient  is  then 
told  to  breathe  deeply  with  the  diaphragm.  In  this  way  it  is  usuallv 
possible  to  detect  the  descent  of  the  kidney.  In  some  cases,  however, 
the  kidney  is  hrst  felt  at  the  moment  it  slips  upwards  into  its  bed. 
The  examination  is  immediately  successful  if  the  patient  is  thin  and  is 
able  to  breathe  according  to  instructions,  but  if  she  is  fat  and  cannot 
carry  out  the  abdominal  type  of  breathing  as  requested,  a  little 
practice  is  necessary.  If  examination  with  the  patient  on  her  back 
yields  no  result,  she  must  be  turned  on  to  her  side — on  to  the  left  side 
for  the  right  kidney — or  she  must  be  examined  in  the  erect  posture. 

What  is  the  iioniuil  degree  of  mobility  ? 

This  varies  in  the  two  sexes.  In  a  male,  it  should  hardly  be 
possible  to  feel  the  lower  pole,  even  of  the  right  kidney ;  but  in  a 
female  there  is  nothing  abnormal  in  being  able  to  feel  the  lower  third. 
In  slender  women  it  may  be  possible  to  feel  even  a  half  of  the  kidney, 
without  the  condition  being  pathological,  whereas  in  a  man  this  should 
certainly  be  regarded  as  an  early  stage  of  movable  kidney.  If  the 
upper  pole  of  the  kidney  can  easily  be  felt,  it  is  obviously  abnormal. 

We  have  been  assuming  that  the  structure  felt  at  the  side  of  the 
abdomen  is  really  the  kidney;  but  this  assumption  is  not  always 
correct.  On  the  left  side,  we  may  be  deceived  by  an  intestinal  tumour, 
but  only  if  we  fail  to  observe  that  the  structure  does  not  move  with 
respiration.  On  the  right  side,  error  may  arise  not  only  from  an 
intestinal  tumour,  but  especially  from  a  constricted  lobe  of  the  liver 
and  from  a  tensely  filled  gall-bladder.  We  have,  however,  discussed 
these  possibilities  in  connection  with  the  surgery  of  the  liver  and 
biliary  passages,  to  which  section  the  reader  is  referred. 

Exceptionally,  it  may  be  quite  impossible  to  arrive  at  a  decision. 
If  the  diagnosis  is  important  from  the  point  of  view  of  treatment, 
some  assistance  may  be  derived  from  a  skiagraphic  examination, 
after  introducing  a  ureteral  catheter,  opaque  to  X-rays,  or  a 
collargol  solution  as  far  as  the  renal  pelvis. 

If  the  structure  felt  is  really  the  kidney,  we  must  next  inquire 
whether  it  is  responsible  for  the  pains  of  which  the  patient 
complains,  bearing  in  mind  that  most  movable  kidneys  never  cause 
any  symptoms  at  all,  even  when  the  degree  of  mobility  is  great. 
On  the  other  hand,  we  should  remember  that  a  movable  kidne\^ 
is  not  usually  an  isolated  phenomenon,  but  is  part  of  a  general 
visceroptosis  which  is,  primarily  or  secondarily,  associated  with  a 
neurotic    state   which    depresses    the    patient,    both    physically   and 


446      SURGICAL   DISEASES   OF   THE   ABDOMINAL   AND   PELVIC   VISCERA 

mentally.  Stiller  calls  this  condition  "  constitutional  asthenia," 
although,  of  course,  this  term  does  not  explain  it.  The  psychical  and 
organic  reflexes  are  abnormally  irritable  in  this  condition,  and  the 
slightest  discomfort — sometimes  even  physiological  processes — is  felt 
as  a  severe  pain,  or,  at  any  rate,  complaint  is  made.  But,  nevertheless,. 
a  movable  kidney  may  itself  give  rise  to  pain  by  attacks  of  so-called 
strangulation — a  term  which  is  meaningless  and  ought  to  be 
abandoned.  These  attacks  are  really  due  to  intermittent  hydro- 
nephrosis, which  will  be  described  in  the  next  chapter,  and  which 
are  produced  by  the  sharp  kinking  or  twisting  of  the  ureter,  as  a 
result  of  the  displacement  of  the  kidney.  But,  apparently,  paroxysms 
of  pain  may  also  be  caused  by  kinking  or  twisting  of  the  renal 
nerves,  also  a  result  of  the  abnormal  mobility  of  the  kidney.  It 
is,  therefore,  better  to  speak  of  torsion,  rather  than  of  strangulation. 
The  polyuria  which  usually  follows  these  attacks,  does  not  depend 
upon  the  discharge  of  urine  which  has  been  dammed  back,  but  upon 
some  reflex  process,  as  is  also  the  case  in  many  instances  of  inter- 
mittent hydronephrosis.  As  abnormal  mobility  of  the  kidney  may 
produce  these  severe  paroxysms,  it  is  only  natural  to  suppose  that 
milder  pains  may  also  be  due  to  the  same  cause.  But  this  assump- 
tion should  only  be  made  under  certain  conditions,  a  main  one 
being  that  the  pain  is  limited  to  the  affected  side,  or,  at  any  rate,  is- 
strictly  distinguishable  from  other  pains  of  which  the  patient  may 
complain.  The  pain  should  radiate  towards  the  inguinal  region^ 
scrotum  and  thigh,  in  contrast  to  the  pain  of  gall-bladder  disease,, 
which  radiates  towards  the  right  shoulder.  The  principal  point, 
however,  is  that  the  pain  is  increased  by  any  movement  which  dis- 
places the  kidney  considerably  downwards  (over-flexing  the  trunk 
backwards,  raising  the  arms  on  high)  and  is  relieved  by  the 
horizontal  posture.  The  pain  is  often  diminished  by  wearing  an 
effectual  binder  on  the  lower  abdomen  (especially  Glenard's  abdo- 
minal binder)  and  also  by  the  support  of  the  gravid  uterus. 

If  the  patient  describes  attacks  which  appear  to  be  due  to 
torsion,  we  must  wait  until  another  one  comes  on,  and  examine 
the  patient  during  its  continuance,  in  order  to  determine  whether 
the  kidney  is  tender  and  swollen.  We  may  then  find  that  the 
pain  has  nothing  to  do  with  the  kidney,  but  that  it  indicates 
an  attack  of  mucous  colitis.  The  same  care  and  repeated  exami- 
nations of  the  bowel  and  stools  are  especially  necessary  when  the 
pains  vary  between  the  right  and  left  side,  although  the  movable 
kidney  is  unilateral.  Such  pains  are  nearly  always  of  intestinal  origin,, 
and  are  usually  accompanied  by  alternating  diarrhoea  and  consti- 
pation, and  by  the  passage  of  some  mucus.  To  attempt  to  stitch 
up   the    sunken  organ  in    such    individuals,  would   usually  mean  ta 


HYDRONEPHROSIS    AXD    ITS    COXSEOUEXCES  447 

operate  on  the  kidneys,  stomach,  colon,  liver  and  uterus.  The  result 
would  probably  be  a  faihire,  because  the  pains  due  to  excessive 
mobility  would  merely  be  replaced  by  pains  due  to  adhesions.  It 
is  this  kind  of  experience  which  has  damped  the  enthusiasm  of 
those  who  were  staunch  advocates  of  stitching-up  displaced  viscera, 
and  it  is  now  recognized  that  a  movable  kidney  does  not  necessarily 
require  stitching,  because  its  anatomical  disposition  is  not  the  only 
matter  to  be  taken  into  account.  These  patients  principally  require 
a  rational  diet  and  a  natural  mode  of  life  to  invigorate  their 
tissues  and  improve  their  nervous  system.  We  may,  indeed,  prescribe 
these  remedies,  but  we  cannot  secure  them  for  the  patients,  because 
some  are  too  low  in  the  social  sphere,  while  others  are  too  high. 


CHAPTER  LXII. 
HYDRONEPHROSIS    AND   ITS    CONSEQUENCES. 

The  retention  of  urine  in  the  pelvis  of  the  kidnev  produces 
a  number  of  clinical  pictures,  varying  with  the  conditions  under 
which  it  has  arisen,  and  each  one  gives  rise  to  its  own  diagnostic 
problems.     We  may  distinguish  : — 

(i)  Closed  Hydronephrosis. — This  appears  as  a  tense  swelling, 
situated  in  the  hypochondrium,  and  its  differential  diagnosis  is 
discussed  in  the  chapter  on  Abdominal  Tumours.  It  is  only 
necessary  to  add  that,  in  rare  instances,  cystic  swellings  which 
do  not  depend  upon  retention  in  the  renal  pelvis,  make  their 
appearance  in  the  kidney  region.  These  are  the  congenital  cystic 
kidneys  (see  also  under  Renal  Tumours),  which  are  distinguishable 
from  hydronephrosis  by  their  nodular  surface,  and  which  are  often 
associated  with  a  cystic  liver.  One  should  also  think  of  hvdatid  cvst 
in  districts  where  this  is  endemic. 

As  has  already  been  observed  in  connection  with  hydatid  of 
the  liver,  unexplained  attacks  of  urticaria  may  suggest  this 
diagnosis. 

If  the  sac  of  a  hydronephrosis  becomes  infected  through  the 
blood-stream,  it  develops  into  a  closed  abscess  with  all  the 
symptoms  of  pus  retention.  Unless  an  exit  is  made  for  the  pus, 
the  perirenal  tissue  may  become  infected,  and,  finally,  also  the 
pleura.     The  following  case  is  typical  : — 


44^      SURGICAL   DISEASES   OF   THE   ABDOMINAL   AND    PELVIC   VISCERA 

A  middle-aged  female  was  suffering  from  a  movable  tumour^ 
which  had  been  discovered  bv  her  medical  attendant  eight  years 
previousty.  An  operation  was  proposed,  but  she  refused,  because 
the  swelling  gave  her  no  pain.  But  after  an  attack  of  influenza  the 
swelling  became  larger,  painful  and  immovable.  High  fever  and 
great  weakness  set  in.  There  was  no  pus  in  the  urine.  Diagnosis  : 
Infected  closed  hydronephrosis.  At  the  operation,  the  perirenal 
tissue  was  found  to  be  already  infiltrated  with  pus,  and  pints  of 
streptococcal  pus  issued  forth  from  the  renal  sac.  The  subsequent 
course  of  the  disease  was  marked  by  suppurative  pleurisy  of  the  same 
side. 

(2)  Open  Hydronephrosis. — This  is  distinguished  from  the  closed 
variety  by  the  fact  that,  within  certain  limits,  its  volume  is  variable. 
It  may  be  subject  to  an  ascending  infection  along  the  urinary  tract,, 
which  cannot  occur  to  a  closed  hydronephrosis,  and  in  this  event 
the  urine  will  contain  pus,   either  temporarily  or  persistently. 

(3)  From  the  point  of  view  of  diagnosis,  intermittent  hydro- 
nephrosis is  the  most  interestmg  form.  It  depends  upon  congenital 
anomalies  in  connection  with  the  renal  pelvis  or  ureter,  or  upon  the 
results  of  a  movable  kidney.  This  latter  cause  acts  most  frequently 
on  the  right  side  and  in  women. 

The  patient,  who  is  either  in  perfect  health  or  has  been  suffer- 
ing from  a  dull  ache  in  the  loins,  is  seized  with  severe  pain 
in  one  kidney — pain  which  radiates  to  the  inguinal  region,  the 
genitals  and  the  thigh.  Sometimes  the  picture  is  completed  by 
vomiting,  great  pallor,  a  collapsed  pulse  and  cold  sweats.  If  the 
hypochondrium  is  examined  at  this  time  it  will  be  found  to  be 
occupied  b}^  a  swelling  varying  in  size  from  a  fist  to  a  man's  head. 
This  swelling  is  sometimes  very  difiticult  to  feel,  because  of  the  reflex 
rigidity  of  the  muscles.  The  symptoms  persist  for  a  few  hours,  rarely 
more  than  a  day,  and  then  subside  after  the  profuse  micturition  of 
clear  urine,  which  occasionally  also  contains  blood.  Sometimes  the 
emptying  of  the  kidney  is  delayed,  especially  if  the  sac  is  large  ;  in 
other  cases  the  kidneys  do  not  return  to  their  normal  volume  between 
the  attacks — remittent  liydvoiiephrosis.  This  may  merge  into  the 
chronic  open  variety,  and,  finally,  into  the  acute  variety.  On  examin- 
ing a  case  of  pure  intermittent  hvdronephrosis  during  a  free  interval 
nothing  abnormal  is  found,  except  perhaps  a  movable  kidney.  The 
diagnosis  may  be  made  in  some  cases  from  the  fact  that  a  swelling 
is  to  be  felt  in  one  side  of  the  abdomen  during  the  attacks  and  that 
they  end  with  the  abundant  evacuation  of  clear  urine,  sometimes 
also  containing  blood.  If,  however,  these  indications  are  not  pre- 
sent, one  must  wait  until  the  next  attack  occurs.  It  is  impossible 
to  miss  the  diagnosis  during  the  attack  itself,  at  any  rate,  if  the 
h^-dronephrosis  has  attained  any  definite  size.  But  in  the  early 
stages  before  the  tumour  has  reached  the  size  of  a  fist  the  muscular 


HYDRONEPHROSIS   AND   ITS   CONSEQUENCES  449 

rigidity  may  render  its  detection  very  difficult.  The  diagnosis  will 
then  lie  between  renal  colic,  biliary  colic  and  even  appendicitis,  the 
last  because  the  pain  radiates  downwards.  But  the  localization  of 
the  pain  on  pressure  and  of  the  muscular  rigidity  in  the  lumbar 
region  is  decisive  against  biliary  colic  or  appendicitis.  Nevertheless 
there  are  cases  wherein  the  question  of  an  attack  of  gall-stones  must 
be  left  in  suspense. 

It  may  be  still  more  difficult  to  distinguish  pure  hydronephrosis 
from  hydronephrosis  due  to  an  attack  of  stone.  If  red  blood-cells 
can  be  demonstrated  in  the  centrifugalized  urine  between  the  attacks, 
and  if  these  cells  increase  in  number  after  active  exercise,  there  is  a 
great  probability  of  stone.  But  this  sign  will  fail  in  the  case  of  a 
small  stone  in  the  ureter.  A  skiagram  should  be  taken  as  a  final 
means  of  diagnosis. 

If  the  renal  pelvis  is  tilled  with  a  colloidal  silver  solution  by 
means  of  a  ureteral  catheter,  it  can  be  rendered  visible  on  the 
skiagraphic  plate. 

If  the  hydronephrosis  has  become  infected  more  or  less  pus  will 
be  found  in  the  urine  during  the  free  intervals,  and  signs  of  infec- 
tion will  be  present  in  addition  to  those  due  to  the  retention,  viz., 
fever,  rigors,  dry  tongue.  The  longer  the  disease  lasts  the  more 
serious  becomes  the  condition  of  the  patient.  Cystitis  follows  the 
hvdronephrosis,  and  the  other  kidney  is  involved  by  an  ascending 
infection.  The  disease  finally  terminates  in  uraemia,  with  or  without 
the  secondary  development  of  stones. 

When  confronted  with  such  a  clinical  picture  as  this,  we  must 
always  inquire  whether  tuberculosis  is  not  responsible,  for  this  may 
for  a  long  time  perfectly  resemble  in  symptoms  a  case  of  infective, 
intermittent  hydronephrosis. 

It  may  be  remarked  in  conclusion  that  intermittent  hydro- 
nephrosis enables  the  practitioner  to  come  to  a  decision  in  regard 
to  the  function  of  the  other  kidney  without  the  process  of  separating 
the  urine.  For  instance,  if  in  a  case  of  aseptic  hydronephrosis 
albumin  is  always  found  in  the  intervals  of  the  attacks — that  is  to 
say,  when  both  kidneys  are  acting — but  is  not  present  during  the 
attacks,  we  may  draw  the  conclusion  that  the  albumin  comes  from 
the  hvdronephrotic  kidney,  and  that  the  other  kidney  is  healthy. 


450      SURGICAL   DISEASES    OF   THE   ABDOMINAL   AND    PELVIC   VISCERA 


CHAPTER  LXIII. 

IDIOPATHIC  SUPPURATION  IN  THE  RENAL  PELVIS 

AND  KIDNEY. 

Urine  which  persistently  contains  pus,  ascertained  by  the  pre- 
viously explained  methods  to  be  coming  either  entirely  or  partially 
from  the  kidneys,  always  raises  the  question  whether  the  suppura- 
tion is  an  independent  process,  or  whether  it  is  a  consequence 
of  some  antecedent  condition,  such  as  hydronephrosis,  stone  in  the 
kidney,  tumour  or  tuberculosis. 

We  purposely  avoid  the  terms  ''primary"  and  ''secondary," 
because  the  manner  in  which  they  are  generally  used  is  liable  to  cause 
misunderstanding. 

An  infection  of  the  kidney  is  primary  when  the  cause  is  intro- 
duced directly  from  without,  and  the  kidney  constitutes  the  first  seat 
of  attack.  The  same  term  is  applicable  if  the  causal  organism  has 
produced  no  pathological  change  at  the  point  of  entry,  but  has 
reached  the  blood,  and  thence  has  become  deposited  in  the  kidney. 

The  suppuration  is  secondary  if  the  kidney  is  not  the  first  organ 
to  be  attacked  ;  for  instance,  if  a  cystitis  has  preceded  the  pyelitis 
(nrogenous  infection) ;  or  if  the  kidney  infection  which  has  taken 
place  is  metastatic,  by  way  of  the  blood-stream,  and  has  arisen  from 
some  anatomically  demonstrable  primary  focus. 

If,  however,  the  renal  suppuration  arises  and  remains  within  the 
kidney  itself  without  the  aid  of  any  other  morbid  condition,  it  should 
be  termed  idiopathic.  If  it  has  followed  any  serious  pathological 
change  in  the  organ,  such  as  tuberculosis,  stone  or  tumour,  we  apply 
to  it  the  term  complication  or  seqnela. 

After  all,  it  is  only  a  matter  of  words,  and  we  might,  with  equal 
justice,  insist  on  some  other  nomenclature.  The  main  point  is,  how- 
ever, always  to  use  the  same  expression  for  the  same  pathological 
process.  No  scheme  has  the  advantage  of  being  strictly  maintained 
throughout,  and  there  are  alwavs  some  processes  which  might  pro- 
perly be  classified  in  various  positions.  For  instance,  pyelitis, 
which  is  caused  by  urinary  obstruction  in  enlarged  prostate,  may  be 
looked  upon  either  as  a  sequela  or  as  an  independent  suppurative 
process.  The  point  turns  upon  the  amount  of  predisposing  influence 
we  will  allow  before  we  abandon  the  conception  of  "  independent 
suppuration."  There  is  really  no  definite  border  line,  and  if  we 
have,  for  example,  fixed  it  on  the  other  side  of  prostatic  hypertrophy 
it  is  solely  for  the  purpose  of  classification. 

Tuberculosis  is  certainly  a  form  of  "idiopathic"  suppuration,  but 
as  we  are  discussing  the  causes  of  acnte  suppuration,  and  as  uro- 
genital tuberculosis  is  clinically  an  independent  disease,  we  will  not 
include  it  here,  but  will  devote  a  special  chapter  to  it. 

When  the  purulent  infection  is  merely  a  seqnela  or  a  complication 
of  an  existing  renal  disease,  it  will  usually  have  been  preceded  by  a 


IDIOPATHIC    SUPPURATIOM    IN    THE    RENAL    PELVIS    AND    KIDNEY      45 1 

stage  wherein  the  symptoms  of  the  primary  disease  have  been  clearly 
manifested,  especially  in  the  case  of  hydronephrosis,  often  also  in  the 
case  of  stone,  and  occasionally,  though  less  definitely,  in  tumours.  If 
not,  we  must  rely  upon  the  physical  examination  for  the  differential 
diagnosis.  An  abscess  sac  as  large  as  an  infant's  head,  or  larger,  does 
not  indicate  idiopathic  suppuration,  but  has  probably  originated  in 
an  old  hydronephrosis.  A  large  irregular  tumour  indicates  a  new 
growth,  A  constant,  although  slight,  admixture  of  blood  with  the 
urine,  in  a  case  of  renal  suppuration  suggests  stone  or  tuberculosis  ; 
greater  haemorrhage  might  also  be  due  to  stone.  But  if  nothing  of 
this  kind  can  be  discovered,  we  may  regard  the  suppuration  as  "  idio- 
pathic "  in  the  above  limited  sense,  and  we  must  search  for  the 
conditions  which  might  account  for  it.  Boils,  erysipelas,  sore  throat 
and  gonorrhoea — in  an  ascending  scale — are  the  main  distributors  of 
infection,  and  pregnancy,  the  puerperium  with  its  deficient  micturition, 
are  causes  of  slight  urinary  obstruction,  in  addition  to  others  already 
mentioned  frequently.  The  midwife  often  provides  the  infective 
material  in  these  latter  cases. 

It  is  only  rarely  that  bacteriological  examination  will  elucidate  the 
matter — for  instance,  if  it  demonstrates  the  presence  of  Staphylococcns 
anreus,  the  pneumococcus  or  the  typhoid  bacillus.  Streptococci  and 
colon  bacilli  are,  however,  such  frequent  denizens  of  diseased  urinary 
passages  that  we  cannot  draw  any  definite  conclusion  from  their 
presence. 

The  gonococcus  is  hardly  ever  found.  This  is,  as  a  rule,  only  the 
first  link  in  the  chain  of  infection,  and  is  followed  by  cystitis  and 
pyelitis  due  to  mixed  infection — these  are  the  second  and  third  links. 
I  have  seen  vesical  stone  and  renal  stone  after  gonorrhoea — constituting 
fourth  and  fifth  links,  and  in  a  similar  case  also  cancer — a  sixth  link. 
Of  course,  a  "harmless"  gonorrhoea  does  not  always  proceed  as  far 
as  this.  More  frequently  a  stricture  is  interposed  in  the  chain  of 
sequelae,  which  may  lead,  in  after  years,  to  an  ascending  urinary 
infection. 

It  is  important  to  ascertain  whether  such  an  infection  is  nnihitcnd 
or  bilateral.  The  etiology  may  help  to  decide  this  point,  for  the 
pyelitis  of  pregnancy  and  post-gonorrhoeal  pyelitis  are  usually  unilateral 
— at  any  rate  at  first — whereas  in  prostatic  patients  it  is  generally 
bilateral.  If  the  disease  is  metastatic  in  origin,  it  may  be  on  one  side 
or  on  both.  If  the  patient  states  that  his  pain  is  sometimes  in  one  loin 
and  sometimes  in  the  other,  the  pyelitis  is  very  probably  bilateral. 
Valuable  diagnostic  points  are  afforded  by  the  demonstration,  by 
palpation,  of  tenderness  on  pressure,  by  reflex  muscular  rigidity  and 
sometimes  by  enlargement  of  the  kidney.  Frequently,  however,  the 
kidney  is  neither  tender  nor  enlarged  wlien  in  a  condition  of  pyelitis. 
It  is  then  advisable  to  attempt  to  palpate  the  ureters,  t'lihei-  per  vagi  nam 


452      SURGICAL    DISEASES    OF   THE    ABDOMINAL   AXD    PELVIC    VISCERA 

or  per  rcchun.  If  they  can  both  be  felt  as  cords,  then  both  kidneys 
are  diseased  (Garre).  A  final  decision  may  be  arrived  at  by  means  of 
the  c^'Stoscope  and  the  separation  of  the  urine. 

The  ancitoinical  diagnosis  presents  the  most  difficult  problem,  and 
it  involves  the  differentiation  of  the  following  conditions — simple 
catarrh  of  the  renal  pelvis,  i.e.,  pyelitis  ;  simultaneous  disease  of  the 
renal  parenchyma,  i.e.,  pyelonephritis  ;  and,  finally,  disease  exclusively 
confined  to  the  parenchyma,  i.e.,  simple  or  multiple  abscess  of  the 
kidney. 

Both  pyelitis  and  pyelonephritis  are  very  frequently  due  to 
ascending  infection,  but  they  are  of  a  hsematogenous  nature,  more 
often  than  was  previously  supposed.  Pain  on  pressure  and  enlarge- 
ment of  the  kidney,  as  well  as  acute  symptoms,  only  occur  in  either 
condition  during  the  stage  of  retention  (pyonephrosis).  The  involve- 
ment of  the  renal  tissue  is  recognized  by  the  fact  that  the  albumin  is 
proportionately  too  high  in  comparison  with  the  amount  of  pus,  and 
also  occasionally  by  the  presence  of  cylindrical  casts.  But  even  in 
the  absence  of  these  signs,  experience  tells  us  that  the  renal  tissue  does 
not  remain  healthy  after  a  long-continued  pyelitis. 

Renal  abscess,  whether  single  or  multiple,  is  the  result  of 
metastasis,  and  is  accordingly  a  pure  infection,  in  contrast  to  an 
ascending  infection,  which  is  usually  of  a  mixed  character.  It  is  easily 
overlooked,  because  there  is  no  pus  in  the  urine  at  first,  and  nothing 
but  the  fever  and  lumbar  pain  indicate  its  presence.  There  is  no 
difficulty  in  distinguishing  it  from  pyelitis,  but  it  is  impossible  to 
differentiate  it  from  early  perinephritis,  and  as  far  as  the  indications 
are  concerned,  it  is  quite  unnecessary.  We  cannot  tell  whether 
multiple  abscesses  are  present,  but  palpation  will  detect  whether  the 
affection  is  unilateral  or  bilateral. 

In  rare  cases  a  renal  abscess  sets  up  so  little  local  reaction  that 
one  is  tempted  at  first  to  think  of  a  new  growth. 

A  man,  aged  60,  came  for  advice  regarding  an  indefinite  pain  in  the 
left  loin.  Examination  showed  that  there  was  in  this  region  a 
moderately  tender,  somewhat  nodular  and  rather  movable  swelling. 
There  was  no  pus  in  the  urine,  but  a  quantity  of  sugar.  There  was 
moderate  pyrexia,  and  the  patient  died  in  a  few  days  from  pyjemia. 
At  the  autopsy  it  was  seen  that  what  appeared  to  be  a  renal  tumour 
was  really  the  kidney,  infiltrated  by  a  well  encapsuled  abscess. 

The  following  case  will  show  how  one  may  occasionally  be  misled : — 

A  middle-aged  man  was  suffering  from  an  old  neglected  gonorrhceal 
stricture,  cystitis  and  intermittent  attacks  of  "  urinary  fever."  He 
received  some  casual  treatment  from  a  chemist,  but  suddenly  became 
ill  with  severe  septic  symptoms,  spontaneous  pain  and  tenderness  on 
pressure  over  the  right  kidney,  which,  however,  was  not  enlarged. 
The  left  kidney  was  slightly  tender,  but  also  of  normal  size.  The 
urine  was  almost  free  from  pus,  which   was  attributed  to  retention 


STONE    IX    THE    KIDNEY    AND    URETER  453 

within  the  pelvis  of  the  right  kidney.  But  nephrotomy  on  the  right 
side  showed  that  there  was  neither  retention  nor  pus.  The  septic 
symptoms  increased  and  the  patient  soon  died.  The  autopsy  revealed 
recent  multiple  non-infective  infarcts  in  both  kidneys,  due  to  vegetative 
endocarditis. 


CHAPTER   LXIV. 
STONE  IN  THE  KIDNEY  AND  URETER. 

Primary  stone  in  the  kidney  plays  a  very  small  part  in  the  renal 
pathology  of  some  countries,  while  in  others  it  is  one  of  the  most 
frequent  of  maladies.  In  some  countries  stone  has  even  become  quite 
a  disease  of  children. 

We  distinguish  primary  from  secondary  stones,  and  we  separate 
the  former  into  a  non-infected  and  a  secondarily  infected  variety. 

.4.— PRIMARY  STONE  IX  THE   KIDNEY. 

(1)   NON-INFECTED  STONE. 

There  are  four  important  symptoms  which  establish  the  diagnosis 
of  nephrolithiasis,  viz.  :  (i)  attacks  of  renal  colic  ;  (2)  dull  aching  pain 
in  one  loin  during  the  intervals  ;  (3)  haematuria,  which  may  be  very 
slight,  but  increases  with  movement;  (4)  presence  of  gravel  or  larger 
concretions  in  the  urine. 

Renal  colic  runs  a  similar  course  in  stone,  as  in  intermittent  hydro- 
nephrosis, with  the  one  difference,  that  the  swelling  due  to  the 
retention  is  not  so  large,  and  that,  in  consequence,  the  urine  which  is 
passed  after  the  attack  is  over  is  smaller  in  quantity  and  contains  less 
blood.  But,  nevertheless,  a  temporary  reflex  polyuria  may  occur. 
The  radiation  of  the  pain  into  the  inguinal  region  may  resemble  an 
appendicitis,  and  the  pain  on  pressure  under  the  liver  may  lead  to 
confusion  with  gall-stones.  Spontaneous  pain  at  the  testicle  is  very 
suggestive  of  renal  stone.    The  testicle  is  very  often  tender  on  pressure. 

Dull  aching  in  Hie  loin  is  a  symptom  of  great  significance,  but  must 
be  employed  with  discretion,  especially  if  there  is  any  doubt  about  the 
diagnosis  of  renal  disease,  as  against  biliary  colic,  for  example. 

We  have  already  dwelt  in  detail  on  Juvinaluria  and  gravel  in  the 
general  section,  and  we  have  seen  that  the  former  symptom  is  more 
constant,    but    less    in    amount,    than    in    cases   of    tumour.     Recent 


454    suR{;icAL  diseases  of  the  abdominal  and  pelvic  viscera 


down  to  lumbago  or  rheumatism. 


observers  have  laid  great  stress  on  the  fact  that  traces  of  blood  in  the 
sediment  of  the  urine,  increasmg  in  amount  after  movement,  may,  for 
a  long  time  be  the  onlv  sii^n  of  stone  in  the  kidnev.  There  mav  be  no 
renal  colic,  and  the  dull  pain  in  the  loin  may  be  entirely  absent,  as 
occurs  with  stones  which  remain  latent  for  years.  These  cases  do  not, 
as  a  rule,  seek  any  advice.  The  traces  of  blood  in  the  urine  are 
discovered  quite  accidentally ;  for  instance,  if  the  patient  consults  his 
doctor  for  indigestion  or  some  other  condition  which  apparently  has 
no  connection  with  the  kidney.     The  dull  pain  in  the  loin  is  often  put 

If  there  be  no  pain  at  all  in  the 
case  of  a  small  stone  sit- 
uated in  the  ureter  and 
causing  no  haematuria, 
a  diagnosis  is  absolutely 
impossible  during  the 
quiet  interval. 

A  skiagraui,  taken  by 
an  expert  and  interpreted 
bv  an  experienced  ob- 
server, should  have  the 
last  word  in  all  diagnos- 
tic difficulties  connected 
with  stone  in  the  kidney. 
The  diagnosis  of  stone 
in  the  kidney  by  the 
X-rays  is  not  easy,  be- 
cause stones  composed 
of  uric  acid  and  of  urates 
only  cast  a  faint  shadow, 
which  in  fat  patients  is 
hardly  perceptible.  But 
the  experience  in  districts 
wherein  this  disease  is 
common  has  been  that 
even  these  stones  often 
contain  so  much  lime 
that  they  may  be  rendered  visible  on  the  plate,  under  proper  con- 
ditions. No  decisive  conclusion  should,  however,  be  made  until 
every  doubtful  appearance  has  been  examined  on  several  impressions. 
The  composition  of  the  stone  is  important  from  a  therapeutic 
aspect. 

If  the  patient  is  a  gouty  subject,  or  if  he  comes  from  a  gouty  stock, 
the  stone  probably  consists  of  uric  acid  or  of  urates,  even  in  children. 
If  crystals  or  gravel  be  found  in  the  urine,  we  shall  obtain  some 
guidance  from  their  microscopic  and  chemical  examination,  the  details 
of  which  have  already  been  referred  to  (Chapter  LIX). 


Fig.  202. — Skiagram  of  stone  in  kidney.      X. 


TUMOURS    OF   THE    KIDNEY  455 

(2)  INFECTED  STONE. 

In  addition  to  the  symptoms  of  aseptic  nephrolithiasis,  those  of 
infection  are  present  :  pus  in  the  urine ;  fever  and  rigors  where  there 
is  retention.  The  correct  diagnosis  is  very  often  missed,  and  the 
condition  appears  to  be  either  an  independent  pyehtis  or  tubercle. 
It  must  be  remembered  that  when  the  ureter  is  temporarily  obstructed 
the  urine  may  be  quite  normal,  because  it  all  comes  from  the  healthy 
kidney,  and  it  is,  therefore,  always  necessary  to  examine  the  urine 
during  an  interval  when  the  ureter  is  not  blocked. 

Z>\— SECONDARY   STONE   IN   THE   KIDNEY. 

Most  renal  concretions  which  occur  in  non-calculous  districts  are 
secondary  in  character.  Their  symptoms  consist  of  those  of  the 
underlying  suppurative  disease,  to  which  are  superadded  the  symp- 
toms of  stone.  The  clinical  picture  is  practically  the  same  as  that  of 
an  infected  primary  stone,  but  the  history  is  different.  In  the  present 
instance,  suppuration  precedes  the  stone  ;  in  the  other  instance  the 
stone  precedes  the  suppuration.  This  consideration  will  indicate  the 
difficulties  which  may  arise  in  differential  diagnosis,  as  well  as  their 
solution,  and  we  will  therefore  not  repeat  what  has  already  been  said. 
Chemically,  all  secondary  stones  consist  of  earthy  phosphates  and 
carbonates.  Their  formation  is  recognized  in  the  urine  by  its  ammo- 
niacal  smell  and  the  abundance  of  triple  phosphates.  Rontgen-rays 
reveal  these  stones  very  clearly,  because  of  their  rich  calcium   content. 


CHAPTER   LXV. 

TUMOURS    OF   THE    KIDNEY. 

Tumours  of  the  kidney,  as  long  as  they  are  not  infected,  at  e 
recognized  by  three  symptoms:  (i)  hcviiiorrliage ;  (2),  local,  and 
especially  radiating  pain;  and  (3)  swelling.  The  predominance  of 
the  one  symptom  or  of  the  other  depends  upon  the  position  or 
manner  of  growth  of  the  tumour. 

Haemorrhage  is  absent  in  very  few  cases  only.  It  is  much  more 
profuse,  but  also  much  more  irregular,  than  in  the  case  of  stone.  If 
the  haemorrhage  is  very  pronounced,  the  clots  may  obstruct  the 
ureter  temporarily,  causing  genuine  renal  colic,  which  must,  however,. 


456      SURGICAL    DISEASES    OF    THE    ABDOMINAL    AND    PELVIC    VISCEKA 

be  distinguished  from  the  persistent  radiating  neuralgic  pain.  It  is 
noteworthy  that  such  haemorrhages  may  continue  for  vears.  The 
radiating  pain  does  not  occur  until  a  late  stage,  so  that  the  haemor- 
rhage, with  or  without  renal  colic,  may  be  for  vears  the  onlv  svmptom 
of  a  small  stationary  tumour  of  the  kidnev,  which  cannot  be  felt.  It 
is  only  by  the  cystoscope,  showing  that  the  blood  comes  from  one 
side,  that  such  a  case  can  be  distinguished  from  chronic  haemorrhagic 
nephritis,  which  may  exist  for  a  long  time  without  albumin  or 
cylindrical  casts.  If  the  cystoscope  does  not  yield  a  decisive  result, 
it  can  then  only  be  obtained  bv  an  exploratory  incision. 

If  the  haemorrhage  is  verv  profuse  and  persistent,  one  should 
think  of  the  possibility  of  a  new  growth  from  the  pelvis  of  flic  kidiicv, 
especially  if  no  appreciable  swelling  can  be  demonstrated,  or  if  the 
examiner  can  feel  a  haematoma  which  is  causing  extreme  distension 
of  the  renal  pelvis  (Israel). 

Persistent,  local,  and  radiating  neuralgic  pain  merely  tells  us  that 
the  tumour  is  malignant,  and  that  operation  will  probal:)ly  be  fruitless. 
If  such  pain  is  unaccompanied  by  any  other  symptom,  the  unfortunate 
diagnosis  of  lumbago  is  often  asci'ibed  to  it,  but  this  is  an  eri"or 
which  tumours  of  the  kidney  share  with  all  painful  diseases  of  this 
region. 

If  the  tumour  is  the  most  striking  symptom  we  must  first  decide 
whether  it  is  really  connected  with  the  kidney.  If  haematuria  is 
present  at  the  same  time  the  matter  is  clear.  But  if  the  urine  is 
normal,  and  the  cvstoscope  shows  that  it  comes  from  both  kidneys, 
then  we  should  think  of  a  liver  or  gall-bladder  tumour  on  the  right 
side,  a  splenic  tumour  on  the  left  side,  and  a  tumour  of  the  large 
intestine  on  either  side.  If  the  timiour  is  of  unusual  size,  an  ovarian 
cyst  should  be  thought  of.  There  is,  however,  one  sign  which 
distinguishes  a  renal  tumour  from  all  of  these,  the  fact  that,  on 
bi-manual  palpation,  it  can  be  felt  most  distinctlv  from  behind,  in 
the  angle  between  the  spine  and  the  twelfth  rib.  A  tumour  of  the 
intestine  would  generally  cause  some  intestinal  disturbance.  A 
tumour  of  the  gall-bladder  has  its  own  special  previous  history,  and 
a  swelling  of  tiie  spleen  betrays  itself  bv  the  sharp  anterior  border, 
which  can  usually  be  felt  quite  easily.  It  is  only  in  the  case  of  an 
irregular  round  tumour  of  the  spleen  that  serious  difBculty  can  arise. 
An  ovarian  tumour  is  recognized  by  the  circumstance  that  when  the 
intestine  is  artificially  distended  it  is  seen  that  the  large  bowel  runs 
over  the  new  growth.  It  takes  the  same  course  in  the  case  of  new 
growth  of  an  ectopic  kidney.  Soft  tumours  of  the  fatty  capsule  of 
the  kidney  (lipomata,  fibromata,  myxosarcomata)  which  may  attain 
a  large  size,  have  hitherto  only  been  diagnosed  at  the  operation. 
They  may  cause  the  most  extraordinary  displacements  of  the  viscera. 

A  cystoscopic  examination  may  enable  a  decisive  opinion  to  be 


TUMOURS    OF    THE    KIDNEY 


457 


given  either  for  or  against  a  renal  tumour  (persistent  absence  of 
urinary  flow  from  one  side). 

Having"  decided  tliat  a  tumour  of  the  kidney  is  present,  we  must 
determine  whether  it  is  a  retention  tumour — hydronephrosis  or 
pyonephrosis — or  whether  it  is  a  genuine  new  growth.  This  point 
is  usually  elucidated  by  the  history  and  the  condition  of  the  urine. 
The  consistence  of  the  tu- 
mour may  be  very  mislead- 
ing, because  a  sarcoma  may 
feel  just  as  elastic  as  a  hy- 
dronephrosis. One  would 
only  think  of  a  hydatid  in 
districts  where  this  disease 
is  rife,  but  localization  in 
the  kidney  is  always  very 
rare.  Exploratory  puncture, 
which  is  occasionally  recom- 
mended, is  just  as  inadvis- 
able here  as  it  is  in  the  case 
of  the  liver,  and  the  serum 
test  is  still  unreliable. 

It  is  difficult,  or  quite 
impossible,  to  infer  any- 
thing about  the  histological 
characters  of  a  renal  tumour 
diagnosed  by  its  clinical 
signs.  There  are  of  course 
cases  wherein  the  uneven 
surface  and  the  slight  mo- 
bility of  the  tumour  stamps 
it  conclusively  as  malignant. 
But  we  often  remain  in 
doubt  because,  as  we  have 
seen,  the  haemorrhage  from 
malignant  tumours  even  may 
persist  for  years.  It  is  only 
rarely  that  external  circum- 
stances permit  us  to  make 
a      definite      diagnosis     on 

clinical  grounds.  This,  however,  applies  to  the  tumours  of  child- 
hood, which  experience  shows  are  either  pure  sarcomata  or  mixed 
sarcomatous  tumom's.  If  there  is  no  haemorrhage  one  would  be 
obliged  to  think  of  hypernephroma,  which  so  often  arises  in  the 
cortex.      If   the    tumour    is    bilateral,    round     and    uneven,    without 


Fig.  203. — Sarcoma  of  the  left  kidney. 


458       SURGICAL    DISEASES    OF    THE    ABDOMINAL    AND    PELVIC    VISCERA 

hjemorrhage  or  suppuration,  and  if  the  discomfort  is  limited  to  a 
dull  pain  with  occasional  renal  colic,  the  only  possible  diagnosis  is 
congenital  cystic  kidney,  especially  if  there  is  also  enlargement  of 
the  liver  (cystic  liver). 

From  the  point  of  view  of  treatment  the  precise  nature  of  a  new 
growth  of  the  kidney  is  not  of  much  importance,  because  as  soon  as 
a  renal  iinnoiiv  has  been  demoiisirated  it  must  be  removed,  unless  it  is 
too   late. 

Cystic  kidneys  are  an  exception  to  this  rule  ;  these  are  only  to  be 
removed  in  the  rare  instances  wherein  it  is  certain  that  they  are 
unilateral,  and  then  onh'  if  thev  cause  sufhcient  trouble  to  justify 
the  operation. 

Finally,  it  must  be  remembered  that  renal  tumours  do  not  always 
occupy  their  normal  position,  resembling  in  this  respect  the  kidneys 
themselves.  Tumours  in  floating  kidneys  are  not  uncommon,  and 
new  growths  may  develop  in  congenitally  displaced  kidneys,  which 
usually  lie  at  the  level  of  the  pelvic  inlet. 

I  once  removed  a  hypernephroma  of  such  a  pelvic  kidney.  Its 
true  nature  was  only  recognized  at  the  operation  by  the  fact  that 
the  kidney  was  absent  from  its  normal  position.  The  clinical 
diagnosis  fluctuated  between  a  solid  ovarian  and  a  renal  tumour. 


CHAPTER    LXVI. 

TUBERCULOSIS  OF  THE  URINARY  PASSAGES. 

Although  the  prognosis  of  tubercle  of  the  urinary  passages  is 
favourable  in  its  early  stage,  the  pi"05pect  is  one  of  the  gloomiest 
when  the  disease  is  advanced.  Unfortunately  the  eai'ly  stage  is  often 
overlooked,  because  it  does  not  declare  itself  very  definitely.  Every 
disturbance  of  the  urinary  organs  of  gradual  onset  should  therefore 
make  one  think  of  tubercle,  and  decide  for  or  against  it,  instead  of 
allowing  the  patient  to  go  about  for  months,  with  the  vague 
diagnosis  of  vesical  catarrh,  vesical  irritation,  or  simply  "  neuras- 
thenia," and  with  unsystematic  or  so-called  "  symptomatic "  treat- 
ment. The  first  symptom  is  usually  a  certain  amount  of  tenesmus. 
The  patient  notices,  as  the  most  striking  objective  sign  of  this  change, 
that  he  has  even  to  get  out  of  bed  once  or  twice  during  the  night. 
This  differentiates  him  from  a  neurasthenic,  who  may  micturate  very 
frequently  during  the  day,  but  is  not  disturbed  at  night.  At  this 
stage,  the  naked  eye    can  detect    nothing  wrong  with  the  urine.     A 


TUBERCULOSIS   OF   THE   URIXARY    PASSAGES  459 

careful  examination  may,  however,  reveal  traces  of  albumen  and  a 
slight  deposit  of  pus  cells,  epithelial  cells  and  isolated  blood  cells, 
in  the  centrifugalized  sediment.  There  are  usually  no  bacteria 
present,  nor  even  tubercle  bacilli.  This  condition  of  the  urine 
absolutely  excludes  a  simple  neurasthenia,  in  which  one  finds  phos- 
phates, carbonates,  calcium  oxalate  and  occasionally  one  or  two 
seminal  threads.  Such  a  urine  supports  the  view  of  some  organic 
disease,  and  the  patient  should  be  thoroughly  examined,  when  it 
is  most  likely  that  some  old  scars  of  glands  or  an  apical  catarrh 
will  be  met  with.  At  this  stage,  palpation  of  the  kidneys  will  not 
usually  yield  any  result,  but  a  tender  spot  will  often  be  found  in 
the  prostate,  especially  on  its  superior  surface,  and  occasionally  also 
a  nodule  in  the  epididymis.  But  if  none  of  these  points  affords  a 
positive  indication  of  tubercle,  it  will  be  necessary  to  inoculate  a 
guinea-pig  with  an  adequate  amount  of  the  scanty  sediment.  It 
may  then  be  found  that,  although  the  recent  examination  of  the 
urine  revealed  no  tubercle  bacilli,  the  animal  becomes  tubercular 
within  four  to  eight  weeks.  In  this  way,  an  early  diagnosis  of 
tubercle  may  be  made,  and  appropriate  treatment  started. 

Having  thus  detected  that  the  urinary  system  as  a  whole  is 
affected  with  tubercular  disease,  we  must  now  search  for  its  point  of 
origin.  Clinical  experience  is  accumulating  proof  that  the  disease 
starts  in  the  kidneys,  or  in  one  of  them.  Spontaneous  pain,  local 
tenderness  on  pressure,  slight  rigidity  of  the  lumbar  muscles,  perhaps 
also  some  demonstrable  enlargement  of  the  organ,  and,  occasionally, 
thickening  of  the  ureter,  felt  through  the  rectum  or  vagina,  will 
show  which  kidney  is  affected.  If  none  of  these  indications  is 
present,  the  practitioner  will  have  done  his  duty  by  referring  the 
patient  to  the  surgeon  as  a  case  of  "  urinary  tuberculosis,"  and  a  case 
may  go  on  for  years  without  definite  indications,  especially  if  the 
tubercular  process  is  developing  itself  in  the  renal  pelvis  rather  than 
in  the  parenchyma.  If  however  the  practitioner  is  able  to  avail 
himself  of  a  cystoscope,  the  inspection  of  the  two  ureteral  openings 
will  show  which  is  the  diseased  side. 

On  the  aft'ected  side  the  margins  of  the  ureteral  opening  are  red- 
dened and  swollen,  whilst  the  orifice  itself  is  often  strikingly  gaping. 
Around  it,  there  maybe  a  few  tubercles  or  small  ulcers.  In  somewhat 
more  advanced  cases  the  urine  which  escapes  is  distinctly  turbid. 

This  examination  is  completed  by  separating  the  urine  within  the 
bladder.  If  this  procedure  is  repeated  several  times  it  yields  most 
useful  results.  Catheterization  of  the  ureters  is  even  more  reliable, 
but  demands  more  skill.  The  question  of  operation  and  its  method 
must  then  be  left  to  the  surgeon.  The  decision  depends  upon  the 
presence  of  a  healthy,  or  at  least  of  an  adequately  functional  and 
non-tubercular  kidney  on  the  other  side. 

30 


460     SURGICAL   DISEASES   OF   THE   ABDOMINAL   AND    PELVIC   VISCERA 

In  this  connection,  it  must  be  emphasized  that  all  these  manipu- 
lations must  be  carried  out  with  special  care  and  with  asepsis.  An 
instrument  should  not  be  introduced  into  a  tubercular  bladder, 
Avhich  is  not  affected  by  a  mixed  infection,  or  only  slightly  so,  unless 
some  definite  diagnostic  information  is  anticipated  from  the  procedure, 
or  unless  it  is  done  for  a  definite  therapeutic  purpose.  Whenever  an 
examination  is  made  with  a  sound,  cystoscope,  separator  or  ureteral 
catheter,  it  should  have  been  preceded  by  the  administration  of  a 
urinary  antiseptic  such  as  urotropine,  or  at  any  rate  be  followed  by  it. 

The  differential  diagnosis  of  the  early  stage  of  urinary  tuberculosis 
varies  with  the  initial  symptoms.  If  JuviiiorrJiage  is  the  predominant 
sign,  as  occurs  in  exceptional  cases,  one  thinks  of  neiv  growth.  If  the 
early  stage  is  characterized  by  renal  colic,  there  is  a  possibility  of 
confusion  with  stone  in  the  kidney,  intermittent  hydronephrosis,  and 
even  with  appendicitis. 

I  once  saw  a  patient  whose  first  symptom  of  renal  tuberculosis 
was  an  attack  which  was  regarded  by  most  experienced  sui'geons 
and  physicians  as  one  of  appendicitis.  The  correct  interpretation 
of  the  condition  was  not  forthcoming  until  the  urine  was  examined. 

If  there  are  no  striking  bladder  symptoms,  but  lumbar  pain  is 
present,  the  diagnosis  of  rheumatism  or  lumbago  usually  suffices,  if 
the  patient  thinks  it  at  all  necessary  to  consult  a  doctor. 

But  there  are  some  cases  in  which  we  must  assume  an  original 
focus  of  tubercle  in  the  kidney,  but  wherein  the  bladder  symptoms 
are  so  predominant  that  they  attract  all  the  attention.  Generally,  it 
is  the  vesical  tenesmus  which  is  so  conspicuous  and  causes  the  patient 
most  torture. 

But  this  is  not  always  a  proof  of  associated  tubercle  of  the 
bladder  ;  because  it  may  arise  reflexly  from  the  kidney.  If  it  is  very 
severe,  it  suggests  the  secondary  formation  of  stone. 

The  later  stages  of  urogenital  tuberculosis  are  often  mainly  charac- 
terized by  this  formation  of  stone,  with  all  the  symptoms  of  secondary 
infected  renal  and   vesical   stones,  with   renal  colic,  fever  and  rigors. 

The  liability  to  secondary  stone  formation  starts,  as  we  have  seen, 
at  the  time  when  the  urine,  which  was  originally  acid,  becomes 
alkaline  owing  to  mixed  infection.  This  affords  us  a  reliable  means 
of  recognizing  whether  the  renal  colic  which  is  present  is  due  to 
stone  or  not.  Sometimes,  however,  this  diagnosis  is  facilitated  by 
the  passage  of  small  concretions. 

It  is  important  to  recognize  this  secondary  stone  formation  early, 
because  the  removal  of  these  stones  will  give  great  relief  even  in 
cases  where,  owing  to  the  tubercle  affecting  both  sides,  there  is  no 
prospect  of  complete  cure. 

In  a  case  of  bilateral  renal  tuberculosis,  where  radical  operation 
was  impossible,  I  removed  a  large  number  of  stones  in  two  sittings 
from  the  right  pelvis,  one  stone  from  the  right  ureter,  and  a  large 
stone  from  the  bladder.     In  this  way  great  relief  was  afforded  to  the 


STON?:    IX    THE    BLADDER  461 

patient  for  about  a  year,  although,  of  course,  it  did  not  prevent  the 
eventual  onset  of  uraemia. 

On  the  other  hand,  we  must  not  attribute,  without  careful  examina- 
tion, a  genuine  case  of  stone  to  suspected  tubercle,  as  has  actually 
happened.  Even  large  vesical  stones  may  cause  no  other  symptom 
but  tenesmus. 

We  must  also  refer  here  to  perinephritis — a  not  infrequent 
complication  of  renal  tuberculosis.  It  occurs  in  two  forms,  which 
are  easily  distinguishable  clinically.  One  form  consists  of  a  sharply- 
defined  abscess  which,  without  any  marked  symptoms,  tracks  down- 
wards or  bursts  through,  in  the  lumbar  region.  Cultures  made 
from  the  pus  are  sterile,  but  an  inoculated  guinea-pig  becomes  tuber- 
cular. This  form  constitutes  the  purely  tubercular  stage  of  the 
disease,  wherein  the  focus  in  the  kidney  bursts  externally  just  as 
a  focus  in  bone  leads  to  the  development  of  a  cold  abscess.  In 
the  other  form  the  perinephritis  manifests  itself  by  acute  symptoms, 
fever,  rigors,  and  severe  pain,  and  instead  of  a  circumscribed  abscess 
W'e  have  a  phlegmon.  This  process  is  really  a  mixed  infection,  and 
its  intensity  depends  upon  the  virulence  of  the  streptococci  or  colon 
bacilli,  &c.,  which  take  part  in  it.  We  must,  therefore,  not  discard 
the  possibility  of  a  tubercular  origin  for  the  renal  malady  because 
of  the  acute  character  of  the  perinephritis.  Tubercle  does  not 
usually  penetrate  lower  than  the  sphincter  vesicae,  but  may  cause 
changes  at  that  site  which  may  be  mistaken  for  late  sequelae  of  gonor- 
rhoea, if  there  be  a  history  of  that  disorder  and  a  bacteriological 
examination  of  the  urine  is  neglected.  Tuberculosis  of  the  genital 
organs  is  not  dealt  with  here,  having  already  been  discussed  in  a 
previous  chapter. 


CHAPTER  LXVII. 
STONE  IN  THE  BLADDER. 

We  differentiate  between  aseptic  and  infected  stones,  just  as  in 
the  case  of  renal  stones. 

(i)  Three  symptoms  point,  as  already  seen  in  Chapter  LIX,  to 
non-infected  stones  in  the  bladder  :  irregular  and  varying  distur- 
bances of  micturition,  not  affected  by  changes  in  posture,  vesical 
tenesmus  and  haemorrhages. 

Obstnictioii  at  the  neck  of  the  bladder  by  a  valve  action  is  very 
significant  of  stone,  but  this  is  frequently  absent,  especially  when  the 


462      SURGICAL    DISEASES    OF    THE    ABDOMINAL    AXD    PELVIC    VISCERA 

Stone  is  large  or  within  a  diverticulum — in  the  latter  circumstance  the 
stone  is  no  longer  aseptic. 

Teiiesuiiis  is  the  result  of  direct  mechanical  irritation,  and  is  very 
marked  in  the  case  of  rough  oxalate  concretions.  The  tenesmus  is 
aggravated  bv  anv  vibration   of  the  body,  especiallv  bv  riding. 

A  patient  of  mine  with  an  oxalate  calculus  always  selected  the 
back  platform  of  a  last  carriage  when  on  a  railway  journey,  so  that  he 
could  empty  his  bladder  from  there,  as  the  need  became  urgent. 
The  luvuion'liage  is  usually  very  moderate,  just  as  it  is  in  renal  stone, 
and  in  contrast  to  the  haemorrhage  of  new  growths. 

Whenever  a  vesical  stone  is  suspected  we  should  investigate  the 
history  in  regard  to  gout,  and  also  search  for  any  indications  of  renal 
stone.  Most  vesical  stones  originate  in  the  kidney,  but  become  large 
in  the  bladder.  We  then  examine  the  urine,  or  the  sediment  obtained 
from  a  large  quantity  thereof,  for  crystals  or  small  concretions.  Then, 
after  the  bowel  is  emptied,  a  bi-manual  examination  of  the  bladder 
is  made  with  one  finger  either  in  the  rectum  or  vagina  and  the  other 
hand  on  the  abdomen.  Large  stones  may  then  be  felt  quite  easily. 
We  may  next  proceed  to  use  the  sound.  This  examination  must 
be  conducted  with  great  patience  and  with  the  bladder  in  varying 
degrees  of  fullness,  if  the  stone  cannot  be  felt  on  the  first  attempt. 
The  sound  also  gives  information  as  to  the  smoothness  or  roughness 
of  the  surface  of  the  stone  ;  in  some  cases  we  may  be  able  to  tell 
its  size,  and  occasionally  also  whether  there  is  more  than  one  speci- 
men present.  If  nothing  can  be  demonstrated,  and  the  suspicion  still 
remains,  we  must  resort  to  the  cystoscope  and  an  X-ray  examination 
(fig.  204). 

The  patient  must  be  undressed  for  this  examination,  otherwise 
one  runs  the  risk  of  opening  the  bladder  for  stone  when  in  reality 
the  shadow  is  due  to  a  trousers  button — an  incident  which  has 
actually  happened. 

An  aseptic  stone  in  the  bladder  may  be  mistaken  for — - 

{a)  Tunioiir  of  the  bladder,  especially  for  a  polypus  at  the  neck 
of  the  bladder,  causing  obstruction  by  \'alve  action,  and  tenesmus — 
a  verv  rare  occurrence.  Such  a  condition  should  be  thought  of,  if 
the  sound  and  the  skiagram  yield  negative  results.  Under  these  cir- 
cumstances a  cystoscopy  is  decisive. 

(b)  Stone  in  the  kidney,  if  the  predominant  symptom  is  reflex 
vesical  tenesmus.  If  there  are  no  renal  symptoms  the  case  can  only 
be  fully  elucidated  bv  X-ray  examination  and  by  the  cystoscope. 
Sometimes  stones  are  present  in  the  kidney  and  in  the  bladder  at  the 
same  time. 

(2)  If  a  bladder  containing  a  stone  become  infected  spontaneously 
or  through  catheterization,  the  previous  symptoms  are  supplemented 
by  suppuration   and   by   an    increase   in    the   tenesmus.      The    other 


STONE    IN    THE   BLADDER 


463 


symptoms  remain  ///  statu  quo.  The  case  is  then  very  hable  to  be 
mistaken  for  some  form  of  cystitis — especiahy  of  a  tubercular  nature. 
Secondary  stones  in  the  bladder  resemble,  in  their  behaviour, 
infected  primary  stones.  They  are  found  as  a  result  of  suppurative 
infection  of  the  urinary  passages  and  of  alkaline,  generally  am- 
moniacal,  decomposition  of  the  urine.  Their  nucleus  is  often  some 
foreign  body,  such  as  a  piece  of  catheter,  a  hairpin,  a  nail,  &c.  The 
history  of  these  secondary  stones  differs  from  that  of  the  infected 
primary  stones,  because  in  the  former  the  infection  either  with  or 
without  a  foreign  body  precedes  the  stone,  whei'eas  in  the  latter  the 
stone  precedes   the    infection — just  as    in   the   case   of    renal  stones. 


Fig.  204. — Skiagram  of  stone  in  bladder. 


The  original  malady  is  often  an  old  gonorrhoeal  or  puerperal  cystitis 
or  one  due  to  spinal  paralysis.  In  other  cases  it  may  arise  from 
urinary  infection  after  an  enlarged  prostate  ;  sometimes  tubercle  is 
the  underlying  cause.  In  rare  cases  it  is  a  congenital  diverticulum 
which  has  led  to  local  congestion  of  urine,  to  the  occurrence  of  a 
spontaneous  infection,  and,  eventually,  to  the  formation  of  stone. 

It  happens  sometimes  that  there  is  no  interference  with  mic- 
turition, which  is  due  to  the  circumstance  that  the  stones  may  be 
firmly  fixed  in  divei  ticula,  or  that  they  may  be  too  large  to  act  as  ball 
valves.     These  cases  manifest  themselves  by  an  extremely  agonizing 


464       SURGICAL   DISEASES   OF   THE   ABDOMINAL   AND    PELVIC   VISCERA 

vesical  tenesmus,  which  cannot  possibly  be  relieved,  and  which 
eventually  resembles  incontinence.  Stones  within  diverticula  are 
easily  missed  by  the  sound,  and  this  makes  their  diagnosis  all  the 
more  difBcult.  Cystoscopy  sometimes  fails  to  yield  the  desired  result 
in  these  cases,  because  of  the  diminution  in  the  capacity  of  the 
bladder,  consequent  upon  the  constant  strangury  ;  but  these  stones 
can  always  be  demonstrated  by  a  skiagram. 


CHAPTER    LXVIII. 
CYSTITIS. 

In  devoting  a  few  lines,  in  addition  to  what  has  already  been  said^ 
to  the  diagnosis  of  cystitis,  the  most  important  consideration  to 
emphasize  is,  that  this  diagnosis  is  made  too  often.  There  is  a 
tendency  to  be  content  with  the  assumption  that  there  is  a  catarrh  of 
the  bladder,  instead  of  ascertaining  the  origin  of  the  trouble.  One 
who  always  diagnoses  cystitis  when  there  is  pus  in  the  urine  and 
strangury  is  present,  will  miss  most  cases  of  prostatic  abscess,  uro- 
genital tuberculosis,  pyelitis  and  infected  stones.  It  matters  not  that 
there  is  some  catarrh  of  the  bladder  present  in  most  of  these  cases^ 
because  it  is  not  the  incidental  malady,  but  the  fundamental  disease 
which  has  to  be  recognized  and  treated.  Even  if  the  cystitis  should 
be  the  primary  and  original  disease,  we  must  not  be  content  with  this 
diagnosis,  but  must,  if  the  disease  does  not  rapidly  recover,  follow  up 
the  secondary  changes — pyelitis  and  stone  formation — which  permit 
of  the  trouble  becoming  chronic. 

The  etiology  renders  the  principal  assistance  in  the  diagnosis  of 
a  primary  cystitis.  Catarrh  of  the  bladder  never  originates  "  of  itself," 
through  some  constantly  prevalent  infection,  like  a  cold.  It  is  always 
due  to  some  definitely  demonstrable  cause — introduction  of  some 
infective  organisms  from  the  kidney  or  from  without,  on  the  one 
hand,  and  such  predisposing  conditions  as  uriuaiy  congestion,  injnries 
and  the  presence  of  foreign,  bodies  on  the  other  hand.  The  more 
virulent  the  organisms,  the  less  individual  predisposition  is  required 
to  evoke  an  attack,  and  vice  versa. 

The  puerperal  bladder,  with  its  dilatory  powers  of  micturition, 
affords  a  well-known  example  of  the  influence  of  even  slight 
congestion. 

The  following  cases  illustrate  the  significance  of  injuries  to  the 
mucous  membrane  : — 


CYSTITIS  465 

A  healthy  young  woman,  in  whom  gonorrhoea  could  be  excluded, 
was  suddenly  seized  with  severe  cystitis,  and  the  passage  of  offensive 
urine.  The  history,  which  was  elicited  with  difficulty,  showed  that  in 
using  a  vaginal  injection  prescribed  by  her  physician,  she  had  by 
mistake  introduced  the  tube  into  the  urethra,  and  this  had  severely 
injured  the  neck  of  the  bladder.  The  bladder  would  have  soon  got 
rid  of  the  infection  if  it  had  not  been  for  the  injury. 

The  same  applies  to  foreign  bodies.  A  practitioner  had  the  mis- 
fortune to  leave  a  piece  of  a  Nelaton's  catheter  in  the  bladder  of  an 
elderly  female.  Severe  cystitis  with  ammoniacal  decomposition 
rapidly  supervened,  and  I  found  the  foreign  body  on  examination, 
fourteen  days  subsequently,  completely  encrusted  with  triple  phos- 
phates. This  cystitis  did  not  signify  that  the  practitioner  was  not 
cleanly  in  his  procedure — he  was  well  acquainted  with  the  theory  and 
practice  of  asepsis — but  simply  that  a  slight,  and  perhaps  unavoidable, 
infection  sufficed  to  provoke  a  severe  catarrh  of  the  bladder  in  the 
presence  of  a  foreign  body. 

I  say  "  perhaps  unavoidable,"  because  we  know  that  even  a  healthy 
urethra  harbours  micro-organisms  which  we  may  introduce  into  the 
bladder,  even  with  the  most  careful  asepsis.  The  reason  that  the 
passage  of  a  catheter  does  not  more  frequently  lead  to  an  infection 
than  it  does,  is  because  the  normal  bladder  is  able  to  dispose  of  most 
micro-organisms  quite  easily.  For  the  same  reason,  cystitis  occurs 
so  rarely  when  micro-organisms  are  excreted  from  the  kidneys  into 
the  bladder.  Indeed,  the  very  fact  of  bacteria  shows  that  micro- 
organisms may  continue  to  develop  in  the  urine  without  injuring 
the  healthy  bladder. 

If  a  large  amount  of  pus  suddenly  appears  from  the  bladder 
without  any  severe  signs  of  irritation  of  this  organ,  the  most  probable 
cause  is  rupture  of  a  perivesical  abscess  into  it ;  the  symptoms  of  the 
original  disease— generally  appendicitis — easily  allow  the  diagnosis 
to  be  made. 

Our  modern  period  of  operations  for  hernia  has  often  witnessed 
infected  sunken  sutures  and  ligatures  make  their  way  into  the  bladder 
instead  of  externally,  and  thus  cause  cystitis,  or  the  secondary 
formation  of  stones. 

If  nothing  points  to  the  cause  of  the  infection  of  the  bladder,  and 
if  its  progress  from  the  start  has  been  very  gradual,  we  shall  rarely  err 
in  ascribing  it  to  tubercle.  Nevertheless  we  often  find,  even  in 
children  and  young  people,  cases  of  obstinate  cystitis,  which  soon 
lead  to  deposits  of  lime,  whose  chronic  character  can  only  be  ex- 
plained by  some  general  decrease  in  resistance,  in  the  sense  in  which 
we  have  used  the  term  scrofula,  but  which  are  not  definitely  tuber- 
cular.    (Chapter  XXIV.) 


466      SURGICAL    DISEASES    OF   THE   ABDO.MIXAL   AND    PELVIC   VISCERA 

CHAPTER    LXIX. 

TUMOURS   OF  THE   BLADDER. 

(1)  TUMOURS   OF   THE  MUCOUS    MEMBRANE    OF   THE 

BLADDER. 

The  chief  symptom  of  these  tumours,  Hke  those  of  the  kidney,  is 
irregular  haemorrhage,  which,  having  once  started,  becomes  very 
severe  and  may  cause  profound  anaemia,  before  any  other  signs 
appear. 

All  the  other  svmptoms  depend  upon  the  position  and  form  of  the 
tumour,  and  upon  complications.  Thus,  if  the  growth  is  near  the 
neck  of  the  bladder  strangury  and  retention  may  occur  ;  if  it  is  of 
polypoid  shape  the  symptoms  are  very  rariahle ;  if  it  soon  begins  to 
invade  the  surrounding  parts,  radiating  pains  are  felt  in  the  region  of 
the  pelvic  nerves  and  the  great  sciatic  ;  if  it  compresses  a  ureteral 
orifice  renat  colic  is  experienced,  and  difficnlty  in  defcecation  if  it  grows 
into  the  rectum.  A  growth  situated  at  the  vertex  of  the  bladder  will 
betray  itself  chieflv  bv  increased  strangury,  in  addition  to  haemor- 
rhage, but,  nevertheless,  this  form  is  one  which  goes  longest  unrecog- 
nized. As  soon  as  cystitis  supervenes,  and  this  rarely  fails  in  growths 
from  the  mucous  membrane,  vesical  tenesmus  occurs  in  addition  to 
haemorrhage,  and  becomes  predominant,  whatever  be  the  situation  of 
the  growth.  This  tenesmus  increases  if  deposits  or  concretions  of 
triple  phosphates  form. 

These  symptoms  having  suggested  a  tumour  of  the  bladder,  vre 
must  examme  the  urine  for  the  narrow  villous-like  shreds,  which  may 
at  once  furnish  a  diagnosis,  or  for  the  greyish-red  pieces  of  tissue 
which  require  microscopic  examination  to  determine  their  nature. 
We  then  palpate  the  bladder  in  the  full  and  empty  state,  after  the 
bowels  have  been  emptied.  Growths  of  the  base  of  the  bladder  can 
be  felt  distinctly,  either  from  the  rectum  or  vagina — frequently, 
however,  as  a  diffuse  resistance  rather  than  as  a  defined  growth. 
New  growths  of  the  vertex  of  the  bladder  can  be  more  easily  reached 
from  the  abdomen,  but  always  by  bi-manual  examination,  even  in  the 
male  sex.  A  fat  patient,  or  one  whose  abdominal  wall  is  unyielding, 
will  require  an  anfesthetic. 

If  we  feel  a  resistant  circumscribed  structure,  it  may  even  be  a 
stone,  which,  if  enclosed  in  a  diverticulum,  will  be  immovable. 
Examination  with  the  sound  and  cystoscope  will  at  once  show 
whether  a  stone  is  or  is  not  present.  Care  must  be  taken  not  to 
mistake  the  not  infrequent  incrustation  upon  a  growth  for  a  stone, 
and  in  using  the  cystoscope  in  a  female  the  uterus  projecting  into  the 


TUMOURS    OF    THE    BLADDER  467 

bladder  must  not  be  regarded  as  a  tumour.  If  sufficient  experience  is 
brought  to  bear  upon  the  interpretation  of  the  cytoscopic  appearance, 
it  should  be  quite  decisive  in  regard  to  the  diagnosis  of  tumour.  But 
sometimes  the  size  of  the  growth  and  the  smallness  of  the  interior  of 
the  bladder  prevent  such  an  examination.  In  such  circumstances, 
however,  palpation  can  elucidate  the  condition,  except  in  the  case  of 
a  very  soft  papilloma.  If  the  cystoscope  does  not  exclude  the 
diagnosis  of  stone,  an  X-ray  examination  should  be  made. 

Stones  and  incrustations  are  both  recognizable  upon  the  skiagram. 
This  aid  to  diagnosis  is  especially  valuable  in  the  case  of  stones  within 
diverticula,  which,  otherwise,  may  easily  be  mistaken  for  growths,  on 
bi-manual  palpation. 

The  question  of  the  innocence  or  malignancy  of  the  growth  is  not 
one  of  great  importance,  because  the  only  histologically  innocent 
tumour  of  the  mucous  membrane — a  papilloma — is  often  clinically 
very  much  on  the  border  line.  A  small  villous  tumour  which  has 
been  removed  quite  early,  mav  be  innocent,  but  an  extensive  papilloma 
approximates  very  much  to  a  malignant  growth,  owing  to  its  tendency 
to  spread  at  its  edges  and  to  recur.  Papillomata  which  are  apparently 
innocent  at  first,  may  eventually  become  cancerous,  and  definite 
cancers  may  originally  have  possessed  all  the  external  characters  of 
papillomata.  A  growth  which  bleeds  and  feels  hard  must  be  regarded 
as  cancer,  without  hesitation. 

If  nothing,  or  at  most  some  indefinite  resistance  in  the  bladder 
region,  is  felt  on  palpation,  we  should  think  of  a  papilloma  as  most 
probably  present.  This  may  invest  the  whole  bladder,  without 
forming  a  large  tumour.  A  cystoscopic  examination  is  indispensable 
in  such  a  case. 

This  sometimes  reveals  the  cause  of  severe  haemorrhages  to  be  a 
small  papilloma,  which  could  not  be  demonstrated  by  any  other 
method.  It  looks  like  a  small  shrub  on  the  mucous  membrane,  or 
like  a  piece  of  red  coral,  presenting  a  most  striking  appearance, 
because  of  the  shadow  which  it  casts. 


(2)  TUMOURS   IN    THE    MUSCULAR    COAT    OF   THE 

BLADDER. 

The  conditions  are  quite  different  when  a  tumour  arises  in  the 
muscular  laver — fibroma,  myoma,  sarcoma.  The  tumour  breaks 
down  and  the  haemorrhage  starts,  if  at  all,  in  a  late  stage,  so  that  the 
disease  is  only  recognized  when  its  extension  compromises  the 
functions  of  the  bladder  by  mechanical  interference.  If  the  new 
growth  is  on  the  posterior  wall  of  the  bladder,  it  may  resemble  a 
myoma  of  the  uterus  growing  forward  ;  an  operation  alone  can  reveal 
the  correct  relations  of  the  tumour. 


468       SURGICAL   DISEASES   OF   THE   ABDOMINAL   AND   PELVIC   VISCERA 

A  myoma  of  the  uterus  sometimes  grows  between  this  organ  and 
the  bladder,  connected  to  the  uterus  by  a  narrow  stalk  only,  displacing 
the  muscular  layer  of  the  bladder  to  a  very  large  extent,  and  may  in 
fact  cause  its  total  disappearance.  On  the  other  hand,  a  fibroma  or 
myoma  arising  in  the  wall  of  the  bladder  may  invade  the  uterus  to 
such  an  extent  that  it  is  only  the  absence  of  a  pedicle  connecting  it 
to  that  organ  which  shows  that  it  is  independent  thereof. 


CHAPTER    LXX. 


HYPERTROPHY,  TUMOURS  AND  ABSCESS  OF  THE 

PROSTATE. 

Although  we  have  already  touched  upon  diseases  of  the  prostate, 
we  will  summarize  once  more  the  most  important  of  them  and  amplify 
our  previous  remarks  by  a  few  points. 

(1)   HYPERTROPHY   AND   TUMOURS. 

If  an  elderly  man  has  constant  trouble  in  emptying  his  bladder, 
although  a  large  catheter  can  be  introduced,  we  should  at  once  think 
of  enlargement  of  the  prostate.  Rectal  examination  will  in  most  cases 
show  that  the  organ  is  enlarged.  If  we  can  inspect  the  interior  of  the 
bladder,  we  will  usually  see  two  lateral  swellings  of  somewhat  unequal 
size  at  its  entrance ;  sometimes  only  one  eminence  in  the  centre 
(clinically  known  as  the  middle  lobe)  ;  occasionally  a  ringed-shaped 
pad-like  projection  is  seen  at  the  neck  of  the  bladder. 

Enlargement  of  the  prostate  does  not  usually  affect  the  whole 
organ,  nor  even  any  special  part  of  it ;  but  consists  generally  of  a 
fibro-adenomatous  proliferation  of  the  tissue  of  the  gland,  which 
immediately  embraces  the  urethra,  and  is  separated  from  the  rest  of 
the  prostate  by  a  layer  of  smooth  muscle.  The  two  lateral  lobes  are 
flattened  by  the  proliferating  mass  and  displaced  to  the  sides.  This 
explains  why  the  hypertrophied  tissue  shells  out  so  easily,  and  also 
that  it  does  not  form  part  of  the  lateral  lobes,  even  when  it  appears  to 
consist  of  two  lobes.  It  also  explains  why  the  vasa  deferentia  are 
not  interfered  with,  and  why,  fortunately,  recurrences  are  so  rare. 

The  wall  of  the  bladder  will  already  in  the  early  stage  present  the 
appearance  of  a  trabeculated  bladder.  In  simple  cases  it  is  quite 
impossible  to  mistake  the  diagnosis. 

We  must  take  care  not  to  confuse  the  early  stage  of  tabes  with 
enlargement  of  the  prostate.     This    is    quite    possible  if  the  tabetic 


HYPERTROPHY,    TUMOURS   AND   ABSCESS   OF   THE    PROSTATE        469 

patient  micturates  frequently  and  has  residual  urine.  The  trabeculated 
condition  of  the  bladder  would  appear  to  support  this  mistaken 
diagnosis,  unless  one  remembers  that  it  also  occurs  in  tabes.  The 
distinguishing  point  is  the  fact  that  the  tabetic  has  genuine  incon- 
tinence. He  allows  his  urine  to  pass  long  before  his  bladder  is  filled 
to  its  maximum,  and  therefore,  as  it  were,  runs  away.  We  should  at 
once  be  very  suspicious  if  the  patient  is  not  well  within  the  age  when 
enlargement  of  the  prostate  is  common. 

Having  diagnosed  hypertrophy  of  the  prostate,  it  becomes  im- 
portant to  ascertain  the  stage  in  which  the  patient  is,  and  also  the 
complications  which  have  taken  place.  The  examination  of  the  urine 
will  show  whether  this  is  infected  ;  the  use  of  the  catheter  immediately 
after  spontaneous  micturition  will  indicate  whether  the  patient  can 
empty  his  bladder  completely  or  has  residual  urine  ;  and  palpation  of 
the  kidneys  wn'll  sometimes — by  no  means  always — inform  us  whether 
any  infection  has  ascended  as  far  as  the  renal  pelvis.  The  diagnosis 
of  pyelitis  can,  however,  be  more  securely  based  on  lumbar  pains, 
sometimes  on  the  right  and  sometimes  on  the  left  side,  on  persistent 
digestive  disturbances,  and  especially  on  acute  attacks  of  retention, 
wnth  fever,  rigors,  vomiting,  diarrhoea,  headache  and  occasionally 
slight  delirium.  These  symptoms  proclaim  that  the  patient  has  arrived 
at  the  condition  which  Guyon  has  classically  described  as  '^  urinaire," 
composed  of  signs  of  uraemia,  at  first  intermittent  and  subsequently 
persistent,  combined  with  septic  absorption.  Infection  very  often 
leads  to  the  secondary  formation  of  stones  w^hich  are  not  necessarily 
free  in  the  bladder,  but  which  may  be  fixed  in  diverticula  like  a  deposit 
in  a  boiler.  They  are  most  commonly  found  in  the  post-prostatic 
pouch,  which  so  frequently  forms  in  prostatic  patients,  and  in  which 
further  diverticula  may  develop. 

This  classical  course  may  be  attended  by  several  variations,  which 
are  important  from  the  diagnostic  standpoint.  Sometimes  the  syui- 
ptoms  appear  to  set  in  snddenlv.  This  may  occur  after  indulgence  in 
an  abundance  of  liquor,  when  the  alcohol  temporarily  paralyses  the 
micturition  mechanism,  or  when  there  has  been  more  opportunity  of 
filling  the  bladder  than  of  emptying  it ;  in  these  circumstances  the 
patient  wakes  up  to  find  that  he  cannot  pass  his  urine.  He  has  care- 
lessly allowed  it  to  become  overdistended,  and  the  detrusor  is  no 
longer  capable  of  overcoming  the  obstruction.  On  close  questioning 
of  the  patient,  one  can  generally  elicit  that  he  has  had,  of  late,  to  get 
up  frequently  at  night,  and  that  the  urinary  stream  has  long  lost  the 
force  which  it  possessed  in  his  youth. 

In  other  cases  the  first  complaint  does  not  concern  difficulty  in 
micturition,  but  rectal  tenesnins,  or  some  unpleasant  sensation  in  the 
rectum  or  perinaeum.  One  patient  complained  of  feeling  "as  if  he 
sat  on  a  bail." 


470      SURGICAL   DISEASES   OF   THE   ABDOMINAL   AND    PELVIC   VISCERA 

Examination  showed  that  there  was  a  distinctly  enlarged  prostate 
in  this  case.  Although  there  was  no  trouble  with  the  urine,  in  the 
ordinary  sense,  the  cystoscope  showed  that  the  bladder  was  definitely 
trabeculated.  The  patient  was  still  in  the  stage  of  perfect  compensation, 
i.e.,  he  had  no  residual  urine. 

In  some  cases,  hcvmorrliages  are  predominant.  They  may  be  very 
profuse  and  cause  rapid  debility. 

Hitherto  we  have  been  assuming  that  the  prostate  is  found 
to  be  enlarged  on  rectal  examination.  But  this  is  not  always  the 
case.  A  middle  lobe  may — not  very  often— be  responsible  for  the 
urinary  difficulty ;  or  a  hard  prostate,  although  not  very  much  en- 
larged, may  be  responsible,  so  that  one  may,  wuth  justice,  speak  of 
"  prostatic  patients  who  have  no  hypertrophy  of  the  prostate."  The 
cystoscope  clears  up  all  these  points,  and  may  also  reveal  a  cancer 
which  has  been  masquerading  in  the  form  of  a  slight  hypertrophy. 

The  more  often  prostates  are  removed  the  more  frequently  does 
one  come  across  carcinoma,  instead  of  the  expected  innocent  hyper- 
trophy. The  whole  subject  of  malignant  growths  of  the  prostate  is 
at  the  present  moment  under  revision,  and  to  all  appearances  the 
diagnosis  does  not  promise  to  be  very  much  facilitated.  A  malignant 
neoplasm  is  at  once  suggested  if  we  feel  an  uneven  asymmetrical 
tumour  in  the  prostatic  region,  growing  towards  the  rectum,  or  if 
we  feel  a  hard  mass,  which  is  not  especially  tender  to  pressure,  but 
is  sharply  defined  at  the  sides.  If  the  cystoscope  reveals  an  uneven 
irregular  structure,  instead  of  the  two  smooth  swellings,  we  should 
make  the  same  diagnosis.  If  a  round  circumscribed  tumour  develops 
in  a  completely  asymmetrical  manner  the  condition  is  very  suspicious. 
It  depends  entirely  upon  the  direction  of  the  growth  whether  rectal 
or  urinary  symptoms  predominate,  but  this  has  no  bearing  on  the 
diagnosis.  The  diagnosis  is  corroborated  if  the  patient  begins  to 
complain  of  sciatica,  or  if  we  find  any  metastases — especially  in  the 
skeleton.  Lt  is  sometimes  possible  to  tell  from  its  shape  whether  the 
tumour  is  carcinoma  or  sarcoma.  If  it  is  hard  and  uneven  we  think 
of  cancer,  if  it  is  soft  and  roundish,  of  sarcoma.  But,  as  already 
stated,  operation  has  shown  that  cancer  is  often  concealed  within  a 
hypertrophy  which  appears  to  be  innocent,  both  to  the  examining 
finger  and  to  the  cystoscope.  The  suspicion  of  cancer  is  not 
confined  to  the  cases  of  pronounced  enlargement,  but  is  shared  by 
the  small  hard  forms.  It  is  not  possible  to  be  dogmatic,  but  we 
may  say  that  every  enlargement  of  the  prostate,  whose  symptoms 
are  on  the  increase,  is  suspicious  of  cancer. 

The  presence  of  cystitis  or  the  formation  of  secondary  stones  do 
not  help  the  diagnosis,  because  these  may  occur  both  with  innocent 
hypertrophy  or  with  cancer.  But  if  persistent  haemorrhages  occur 
the  case  is  very  suggestive  of  cancer. 


HYPERTROPHY,    TUMOURS   AND    ABSCESS   OF   THE   PROSTATE        47 1 

(2)   INFLAMMATORY    PROCESSES. 

Chronic  irritative  conditions  of  the  prostate,  such  as  occur  in 
gonorrhoea!  cases,  are  of  much  less  interest  to  the  surgeon  than 
prostatic  abscess  proper.  If  a  patient  suffers  from  rectal  tenesmus 
and  severe  pain  on  defcccation,  upon  which  symptoms  there  super- 
vene shortly  afterwards  strangury  and  possibly  also  complete 
obstruction  of  the  urethra,  it  is  obvious  that  there  must  be  some 
acute  inflammatory  process  between  the  rectum  and  the  exit  from 
the  bladder,  i.e.,  in  the  region  of  the  prostate.  If,  on  passing  a 
finger  into  the  rectum  and  on  feeling  over  one  of  the  lateral  lobes, 
we  detect  a  soft  or  elastic  swelling  over  which  the  mucous  mem- 
brane is  thickened  like  velvet,  we  diagnose  an  abscess.  The  speculum 
shows  the  mucous  membrane  to  be  oedematous  and  sodden,  but 
otherwise  it  does  not  give  such  a  realistic  picture  of  the  disease  as 
the  finger  does.  The  introduction  of  a  Nelaton  catheter  into  the 
urethra  will  encounter  a  more  or  less  definite  obstruction. 

Metal  catheters  should  not  be  used  in  these  cases,  because  they 
may  easily  injure  the  oedematous  mucous  membrane. 

It  sometimes  happens  that  the  whole  clinical  picture  disappears 
suddenly  by  itself,  with  the  discharge  of  pus  into  the  rectum  or 
into  the  bladder,  or  into  both,  and  the  patient,  thus  relieved,  begs  us 
to  put  aside  the  knife  which  was  held  in  readiness.  But  if  this 
simple  termination  does  not  occur,  we  must  operate  in  order  to  give 
relief. 

The  cause  of  the  abscess  is  important  from  the  point  of  view  of 
prognosis.  The  principal  question  to  decide  concerns  its  gonor- 
rhoea! or  tubercular  origin,  and  there  is  not  usually  any  difficulty  in 
this.  Gonorrhoea,  even  if  not  confessed  to,  may  usually  be  recog- 
nized at  the  stage  wherein  it  causes  a  prostatic  abscess,  by  the 
remains  of  urethral  discharge.  But  it  is  also  necessary  to  be  able 
to  demonstrate  the  presence  of  the  gonococcus.  The  discharge  of 
the  pus  from  the  abscess  into  the  urethra,  which  does  not  always  pour 
out,  but  may  only  exude  drop  by  drop,  may  completely  resemble 
an  active  gonorrhoea,  and  it  is  therefore  indispensable  to  examine  the 
pus  microscopically,  when  the  history  is  negative. 

A  young  man  had  a  typical  bilateral  prostatic  or  periprostatic 
abscess.  On  examination  a  few  drops  of  thick  pus  exuded  from  his 
urethra,  and  he  appeared  to  have  a  recent  gonorrhoea.  But  this 
suspicion  could  be  put  aside,  absolutely  definitely,  for  the  bacterio- 
logical examination  showed  a  pure  culture  of  Staphylococcus  aureus. 
The  patient  had  recently  suffered  from  a  large  boil  on  his  sacrum. 

If  nothing  points  to  gonorrhoea  we  should  think  of  tubercle,  and 
if  the  symptoms  have  come  on  suddenly  the  infection  is  a  mixed  one. 

A  young  man  with  a  very  tubercular  family  history  became  ill 
suddenly   with   typical    symptoms  of  prostatic  abscess.     Gonorrhoea 


472       SURGICAL   DISEASES    OF   THE    ABDOMINAL   AND    PELVIC   VISCERA 

could  be  excluded.  The  abscess  opened  into  the  bladder  and  the 
pus  contained  a  pure  culture  of  the  Bacillus  coll.  A  guinea-pig 
inoculated  with  the  pus  became  tubercular.  Nevertheless  the  focus 
in  the  prostate  healed  rapidly,  so  that  without  the  inoculation  the 
diagnosis  would  have  remained  doubtful. 

If  both  tubercle  and  gonorrhoea  are  excluded  we  must  think 
of  some  other  source  of  infection,  as  in  the  case  previously 
mentioned. 


CHAPTER  LXXI. 
INJURIES  OF  THE  URETHRA. 

The  injuries  which  concern  the  posterior  portion  of  the  urethra 
possess  the  greatest  diagnostic  interest.  They  are  divisible  into  three 
groups:  (i)  Injuries  from  within  the  urethra;  (2)  injuries  produced 
by  external  violence  without  causing  a  wound;  and  (3)  the  con- 
sequence of  fracture  of  the  pelvis. 

False  passages  play  an  important  part  in  the  causation  of  injuries 
from  within  the  urethra.  A  haemorrhage,  which  is  generally 
rather  severe,  warns  the  practitioner  who  passes  a  catheter  carelessly, 
or  the  patient,  that  some  damage  has  been  done. 

These  injuries  are  most  easily  inflicted  by  the  so-called  English 
catheters,  which  were  formerly  in  considerable  vogue  and  were  given 
to  patients  for  their  own  use  as  being  harmless.  Unfortunately  they 
have  not  entirely  gone  out  of  fashion.  They  are  not  stiff  enough 
for  introduction  wnthout  a  stylet,  but  are  quite  stiff  enough  to  do 
some  damage. 

Injury  by  such  articles  as  pencils,  nails,  hairpins,  &c.,  are  less 
general.  One  should  think  of  this  possibility  if  a  patient  otherwise 
healthy — at  any  rate,  physically — bleeds  from  the  urethra  and  has 
pain  on  micturition,  apparently  without  cause.  It  would  appear 
from  English's  summary  that  almost  everything  which  could  possibly 
get  in  has  been  found  in  the  urethra. 

Contusion  of  the  urethra  by  violence  which  causes  no  external 
wound  is  of  great  practical  importance.  If  one  falls  astride  on 
the  edge  of  a  board,  on  a  pommel,  or  a  bicycle  wheel  or  some 
similar  object,  the  urethra  is  crushed  between  the  pubic  arch  and 
surface  on  which  it  rests.  A  kick  on  the  perinaeum  produces  a 
similar  result  in  a  different  way.  The  symptoms  which  are  observed 
after  such  an  injury  indicate  very  distinctly  the  nature  of  the 
anatomical    damage,    even   without    passing   a   catheter.      This   pro- 


INJURIES    OF   THE    UKETHRA  473 

ceeding,  which  is  not  ahvays  free  from  danger,  should  be  the  final 
step  in   diagnosis. 

The  following  forms  may  be  distinguished  in  this  variety  of 
injury  : — 

(i)  If  the  patient  has  some  trouble  in  micturating,  but  is  able 
with  a  certain  amount  of  force  to  empty  his  bladder  of  urine,  which 
is  free  from  blood,  he  has  sustained  3.  pcri-uretliral  IhTiuatoiua  without 
anv  injury  of  the  mucous  membrane.  The  effusion  of  blood  may 
be  felt  in  the  perinaeum  as  a  hard  exudate.  The  catheter  should  not 
be  used  as  long  as  the  patient  can  pass  his  urine. 

(2)  If  some  blood  comes  with  the  first  few  drops  of  urine, 
although  the  bladder  can  be  completely  emptied,  some  slight  injury 
1ms  been  inflicted  on  tlie  niucons  nienibrane ;  but  the  passage  of 
a  catheter  is  not  justified  unless  signs  of  extravasation  of  urine 
appear. 

(3)  But  there  is  another  series  of  symptoms  which  occur  with 
such  constant  uniformity  that,  once  seen,  they  can  never  fail  to  be 
recognized.  The  patient  lies  groaning,  because,  notwithstanding 
strong  contractions  of  the  bladder,  and  his  own  pressure,  he  can 
only  evacuate  pure  blood  from  the  urethra,  although  the  bladder  is 
quite  full.  There  is  a  hard,  dark  blue  swelling  which  extends 
symmetrically  like  a  butterfly's  wings  on  either  side  of  the  perinasum. 
The  longer  one  waits  the  more  tense  becomes  the  swelling  and  the 
patient's  condition  more  agonizing.  In  the  presence  of  such  a 
clinical  picture  the  diagnosis  is  clear  enough  without  passing  a 
catheter.  The  patient  has  a  complete,  or  almost  complete,  rupture 
of  the  urethra,  and  all  the  urine  which  the  bladder  cannot  retain 
is  being  extravasated  into  the  connective  tissue  of  the  perinjeum. 
The  urine  must  inevitably  decompose  unless  relief  is  given  by  opera- 
tion. As  a  rule  the  catheter  is  held  up  at  the  site  of  injury,  and  it 
would  only  be  a  lucky  accident  if  it  entered  the  bladder  by  following 
up  the  anterior  surface  of  the  urethra,  which  sometimes  is  not  torn 
through.  The  fact  that  such  a  luck}^  accident  is  possible  justifies 
a  cautious  attempt  at  passing  a  catheter,  but  we  must  be  careful  not 
to  draw  a  false  conclusion.  Clinical  records  often  relate  that  the 
practitioner  has  withdrawn  a  certain  amount  of  bloody  urine,  but 
the  patient  experiences  no  relief  therefrom.  If  we  make  the  attempt 
we  shall  arrive  at  the  same  result,  and  at  the  same  time  feel  that  we 
have  not  succeeded  in  entering  the  bladder.  The  explanation  is 
probably  that  the  urine,  which  is  escaping  from  the  bladder  under 
pressure,  has  found  a  cavity  for  itself  in  the  perinaeum,  which  holds 
a  certain  quanity  of  blood  and  urine.  In  such  cases  we  should  not 
persist  with  the  catheter,  but  must  at  once  provide  for  emptying  the 
tissues  of  urine  by  a  perinatal  incision. 


474      SURGICAL   DISEASES   OF   THE   ABDOMINAL   AND   PELVIC   VISCERA 

Obstruction  of  the  urethra  through  a  fractured  pelvis  is  of  less 
frequent  occurrence.  The  considerations  mentioned  in  connection 
with  contusions  from  without,  apply  here  also.  The  difticult  evacua- 
tion of  pure  urine  without  blood  strongly  suggests  compression  of 
the  urethra  by  a  haematoma,  such  as  would  occur  in  the  case  of  frac- 
ture of  the  symphysis.  But  the  cause  may  be  kinking  of  the  urethral 
canal,  due  to  its  being  dragged  on  by  the  displacement  of  the  two 
pubic  bones  one  against  the  other.  If  the  normal  function  return 
within  a  few  days,  and  if  a  catheter  passed  subsequently  encounters 
no  obstruction,  the  case  is  one  of  a  simple  haematoma.  But  if  we 
still  meet  with  some  obstruction  after  the  lapse  of  time — obstruction 
which  cannot  be  overcome  at  all,  or  which  requires  some  special 
form  of  catheter  or  some  special  manoeuvre  to  do  so — we  must 
assume  that  there  is  a  kink  in  the  urethra  due  to  displacement  of 
the  bones,  although  there  may  be  little  difficulty  in  spontaneously 
emptying  the  bladder. 

In  these  cases  the  skiagrams  show  that  one  pubic  bone  overrides 
the  other  to  the  extent  of  one  or  more  centimetres. 

If  blood  is  passed  with  the  urine,  the  urethra  is  certainly  injured — 
perforated,  crushed,  or  lacerated  by  a  fragment — but  not  torn  right 
through.  A  catheter  must  not  be  passed  in  such  a  case,  as  long  as  the 
bladder  can  empty  itself  and  there  is  no  extravasation  of  urine. 

If  nothing  but  blood  comes  from  the  urethra,  and  the  bladder  fills 
up,  while  signs  of  extravasation  of  urine  appear,  we  must  decide  to 
adopt  the  same  treatment  as  in  the  cases  which  manifest  the  same 
symptoms  after  external  contusion. 


CHAPTER     LXXII. 
SURGICAL   DISEASES   OF   THE    PENIS. 

Injuries  or  deformities  of  the  penis  present  no  diagnostic  difficul- 
ties. The  so-called  fractures  or  dislocations  of  the  organ  are  only 
curiosities,  and  have  little  practical  importance.  Constriction  is  easy 
to  recognize,  if  effected  by  means  of  the  neck  of  a  bottle  or  a  female 
screw,  but  not  so  easy  if  a  wire  ring  or  a  loop  of  thread  has  been 
employed.  The  last  may  cut  so  deeply  into  the  penis  that  surgical 
interference  is  required  to  render  it  visible  and  to  remove  it.  A 
similar  condition  is  seen  in  paraphimosis  caused  by  the  retraction 
of  a  tight  prepuce  (fig.  205). 


SURGICAL   DISEASES   OF   THE    PENIS 


475 


In  the  case  of  deformities,  the  first  glance  shows  whether  the  cleft  is 
above  or  below,  whether  epispadias  or  hypospadias  is  present.  The 
degree  of  the  latter  is  determined  by  the  place  at  which  the  urethral 
orifice  is  situated.     (See  reference  to  Hermaphroditism,  Chapter  L). 

Tumours  and  ulcers  are  much  more  important  from  the 
diagnostic  standpoint.  For  practical  purposes  we  must  differentiate 
between  subcutaneous  growths  on  the  one  hand  and  inflammatory 
ulcers  or  ulcerated  growths  on  the  other  hand. 


(1)  SUBCUTANEOUS  GROWTHS. 

These  very  rarely  occur  on  the  penis.  Sebaceous  cysts  and 
dermoids  are  the  only  innocent  growths  which  ever  occur,  and 
sarcoma  the  only  malignant  one.  The  former  are  either  in  the  skin 
or  under  it  ;  the  latter  usually  arises  in 
the  corpora  cavernosa.  The  diagnosis 
presents  no  difficulty,  but  one  must  not 
mistake  the  hard  nodular  or  cord-like 
induration  which  indicates  chronic  in- 
flammation of  a  corpus  cavernosum 
for  a  commencing  sarcoma.  Bony 
growths  in  the  penis,  which  are  very 
rare,  are  easily  recognized  by  palpation 
and  X-ray  examination.  Elephantiasis, 
a  condition  which  is  very  frequent  in 
the  Tropics,  is  not  really  a  growth,  but  it 
converts  the  penis  into  a  club-shaped, 
and  finally  into  an  enormous  and  shape- 
less tumour,  A  similar  condition  occurs 
in  other  countries  after  repeated  attacks 
of  erysipelas. 

(2)  ULCERATIVE  CHANGES. 

In  addition  to  venereal  ulcers  there  exists  a  whole  series  of  inter- 
mediate clinical  forms,  ranging  from  acute  inflammatory  conditions 
to  an  ulcerating  cancer,  which  require  complete  exposure  of  the  glans 
— sometimes  with  the  aid  of  the  knife — before  they  can  be  diagnosed. 

(a)  If  there  be  pronounced  inflammation  of  the  foreskin  and  glans 
at  an  age  when  venereal  infection  is  more  or  less  infrequent,  we  should 
think  of  simple  balanitis  or  balano-posthitis.  In  young  lads,  the 
cause  is  almost  always  phimosis;  in  old  people  it  may  also  be  due  to 
retention  of  smegma  or  narrowing  of  the  foreskin.  If  the  inflamma- 
tion is  very  pronounced  or  very  obstinate,  or  if  it  dates  from  middle 
age,  the  urine  should  be  examined  for  sugar — always  assuming  the 
presence  of  a  certain  degree  of  retention  of  smegma. 

31 


Fig.  205. — Paraphimosis. 
=  Penis,    b  =  Constricting  furrow, 
c  =  Prepuce,     d  =  Glans  penis. 


476      SURGICAL   DISEASES   OF  THE   ABDOMINAL    AND    PELVIC   VISCERA 

Sometimes  considerable  inflammation  of  the  foreskin  or  glans 
occurs  in  the  course  of  severe  acute  infective  fevers. 

It  is,  of  course,  obvious  that  the  inguinal  glands  may  enlarge  in  all 
these  conditions.  Extensive  lymphangitis  and  phlegmonous  compli- 
cations may  exceptionally  occur. 

(6)  If  venereal  disease  is  not  excluded — there  is  no  age  limit  in 
regard  to  chancre,  and  even  impotence  is  no  guarantee  against  it — the 
prepuce  and  glans  must  be  carefully  examined,  and  a  diagnosis  of 
balanitis  must  not  be  made  unless  it  is  quite  certain  that  no  circum- 
scribed ulcer  is  present.  It  is,  of  course,  important  not  to  confuse  a 
superficial  erosion  with  a  genuine  ulcer.  Erosions  may  occur  in  any, 
case  of  balanitis,  and  are  especially  common  in  herpes  genitalis.  But 
they  heal  in  a  very  few  days  with  any  mild  treatment  if  the  part  is 
kept  clean,  whereas  a  real  ulcer  takes  a  long  time  to  scar  over. 
Sometimes  a  hard  chancre  looks  like  a  superficial  erosion,  but  it  can 
be  easily  distinguished  from  a  harmless  erosion  bv  its  indurated  base. 

(c)  If  the  disease  does  not  consist  of  any  diffuse  change,  but 
merely  of  a  circumscribed  ulcer,  we  have  to  think  of  those  conditions 
which  we  have  already  studied  in  connection  with  the  oral  mucous 
membrane,  although,  of  course,  they  do  not  occur  in  the  penis  with 
anything  like  the  same  frequency.  A  tubercular  ulcer  has  been 
observed  on  the  foreskin  and  glans  in  cases  of  uro-genital  tuberculosis, 
but  it  is  extremely  rare. 

Instances  have  been  recorded  wherein  tubercular  lesions  have 
followed  suction  of  the  blood  by  a  tubercular  operator,  after  ritual 
circumcision. 

The  problems  of  diagnosis  mainly  centre  around  the  differentia- 
tion between  soft  and  hard  chancres,  gumma,  and  cancer.  An  ulcer 
which  appears  a  few  days  after  sexual  intercourse  is  usually  a  soft 
chancre,  but  it  may  become  a  hard  chancre  within  two  or  three 
weeks.  The  former  diagnosis  is  proved  by  the  onset,  within  a  few 
days,  of  diffuse  infiltrating  and  painful  buboes.  The  diagnosis  of 
subsequent  syphilitic  transformation  is  proved  by  the  obstinacy  with 
which  the  chancre  resists  non-specific  treatment,  by  the  demonstra- 
tion of  spirochete,  and  by  the  serum  test,  but  above  all  by  the  appear- 
ance of  constitutional  symptoms.  If  the  ulcer  has  not  appeared  until 
after  two  or  three  weeks'  incubation,  the  diagnosis  of  a  hard  chancre 
is  quite  certain  ;  the  discovery  of  spirochetal  and  tiie  onset  of  glandular 
enlargement  after  another  couple  of  weeks,  only  serve  to  confirm  the 
diagnosis. 

The  diagnosis  is  more  difficult  when  a  patient,  who  has  just  entered 
within  the  cancer  period,  denies  all  possibility  of  infection — an  old 
proverb  says  "  Omnis  syphiliticus  mendax."  No  denial  is  of  avail  in 
the  presence  of  a  soft  chancre  with  rapidly  forming  buboes,  and  the 


SURGICAL    DISEASES    OE    THE    PEXIS 


477 


diagnosis  of  hard  chancre  only  requires  a  little  patience  if  a  search 
cannot  at  once  be  made  for  the  spirochjete.  Consequently,  there  can 
only  be  anv  real  doubt  as  between  gumma  and  cancer.  Experience 
shows  that  an  error  of  diagnosis  may  damage  a  practitioner  both  in 
reputation  an.d  in  money.  If  he  amputates  for  a  gumma,  as  has 
actually  happened,  he  becomes  responsible  for  wanton  mutilation. 
If  he  treats  a  cancer  for  weeks  or  months  as  a  gumma  he  runs  the 
danger  of  converting  a  curable  malady  into  an  incurable  one,  and  the 
patient  will  make  him  responsible  for  the  lo_ss  of  the  organ,  But  both 
mistakes  are  avoidable  by  a  little  examination.  A  cauUftower-like 
cancer,  if  definite,  is  immediately  recognizable.  This  form  usually 
follows  an  old  phimosis,  and  in 
time  ulcerates  through  the  external 
foreskin.  A  ficit  cancer  bears  more 
resemblance  to  a  svphilitic  ulcer, 
but  it  lacks  the  fatty  base  of  the 
gumma.  The  inednUarv  noclule- 
fonning  cancel'  is  quite  unmistak- 
able. 

We  have  already  seen  that  the 
glands  do  not  enlarge  in  cases  of 
gumma,  and  that  their  enlargement 
may  be  absent  in  cases  of  cancer,  or 
supervene  at  some  later  time,  where- 
as the  enlarged  glands  in  connec- 
tion with  a  hard  chancre  always 
appear  at  the  classical  moment. 

If  any  doubt  still  persists,  a  small 
piece  of  the  base  of  ulcer  should 
be  taken  for  microscopical  exam- 
ination. A  positive  diagnosis  can 
then  be  obtained  within  a  few  days, 
and  until  then  no  suggestion  should 

be    made    for   the   removal    of   the  penis  ;    otherwise    the  patient   is 
perfectly  justified  in  rejecting  such  a  proposal. 

Cancer  can  often  be  detected  in  its  early  stage,  when  phimosis  is 
present,  by  the  offensive  discharge  from  the  prepuce. 

Finally,  some  confusion  is  conceivable  between  a  commencing 
papillary  cancer  and  an  acuminate  condyloma.  The  assertion  that 
the  latter  is  always  a  consequence  of  gonorrhoea  is  incorrect,  and  is 
misleading  to  diagnosis.  Acuminate  condyloma  is  an  infective  condi- 
tion of  its  own  ;  but  is  distinguished  from  cancer  by  its  invariably 
soft  base. 

The  significance  of  phimosis  may  be  inferred  from  the  statement 
of  Barney  that  Jews  very  rarely  suffer  from  cancer  of  the  penis.    Just 
as  other  cancers,  this  form  may  also  develop  in  a  venereal  scar. 
31A 


Fig.  206. — Cancer  of  glans  penis. 


PART    V. 

THE  SURGICAL  DISEASES  OF   THE 
PELVIS   AND  SPINAL   COLUMN. 


CHAPTER    LXXIII. 
TUMOURS    OF   THE    PELVIS. 

The  major  portion  of  the  pelvis  is  so  extensively  covered  by  soft 
parts,  that  it  is  very  easy  to  overlook  tumours  in  their  early  stage,  even 
if  they  do  not  grow  exclusively  inwards.  It  is  therefore  most 
important  to  devote  due  and  timely  attention  even  to  their  indirect 
symptoms. 

If  a  pelvic  tumour  grows  inwards,  it  will  sooner  or  iTiier  press  upon 
and  displace  the  pelvic  organs.  Bladder  and  rectal  derangements  will 
usually  point  to  this  result.  A  definite  conclusion  can  only  be  formed 
after  a  careful  bi-manual  examination,  per  rectum  and  the  lower 
abdominal  region,  an  examination  which  should  never  be  neglected  in 
any  obscure  case  of  bladder  disturbance. 

The  derangements  which  occur  during  labour  are  well  known,  and 
they  may  be  imitated  by  tumours  within  the  pelvis,  even  if  they  are 
small.  The  experienced  obstetrician  will  always  think,  among  other 
possibilities,  of  a  new  growth  in  the  pelvis,  when  the  head  of  a  child 
refuses  to  engage  normally. 

Symptoms  of  displacement  of  the  pelvic  viscera  are  not  always 
predominant  in  the  clinical  picture.  If  the  growth  extends  mainly 
outwards,  or  if  it  is  situated  in  the  false  pelvis,  it  gives  rise  to  two 
other  symptoms — the  appearance  of  a  protuberance  in  some  part  of  the 
pelvis,  and  the  result  of  pressure  on  the  nerve-roots.  A  new  growth  of 
the  pubic  crest  is  distinguished  by  the  early  stage  at  which  it  can  be 
seen  and  felt.  It  requires  no  further  diagnostic  consideration.  But  a 
growth  more  often  announces  itself  by  nerve  disturbances  long  before 
it  can  either  be  seen  or  felt,  and  the  patient  is  accordingly  provided 
with  various  diagnoses  and  ordered  to  all  possible  spas. 

A  man,  aged  52,  had  consulted  many  doctors  for  sciatica.     At  our 


TUMOURS   OF   THE   PELVIS  479 

first  examination  no  organic  cause  for  the  neuralgia  was  evident. 
The  rectum  was  free,  the  prostate  normal,  and  nothing  could  be  felt 
in  the  pelvis.  The  spinal  column  was  also  normal.  The  treatment 
for  the  sciatica  had  apparently  secured  temporary  improvement. 
The  patient  returned  in  nine  months'  time,  and  then  it  was  clear 
that  the  pains  affected  the  region  supplied  by  the  anterior  crural  nerve 
rather  than  the  sciatic  nerve  region ;  at  the  same  time  there  was  a 
striking  weakness  of  the  flexors  of  the  thigh.  The  patient  had  to  lift 
up  his  left  leg  with  both  hands  to  put  it  on  the  examination  stool. 
In  addition  there  were  pains  in  the  lumbar  region;  the  twelfth  dorsal 
vertebra  and  the  centre  of  the  sternum  were  painful  to  pressure.  The 
diagnosis  of  "sciatica"  was  obviously  discredited,  and  one  had  to 
think  of  organic  damage  to  the  great  nerve-roots  which  supply  the 
left  leg.  Meanwhile  a  tumour  of  the  left  iliac  bone  had  become 
palpable  on  deep  pressure,  and  this  explained  all  the  symptoms.  A 
loud  souffle  could  be  heard  with  the  stethoscope  over  it,  and  this 
confirmed  the  diagnosis  of  "sarcoma."  The  pain  over  the  lumbar 
spine  and  the  sternum  indicated  metastases,  which  therefore  contra- 
indicated  any  operative  interference. 

It  is  not  always  pressure  on  nerves  which  suggests  a  concealed 
pelvic  tumour ;  sometimes  the  pressure  is  exerted  on  blood-vessels, 
producing  an  increasing  oedema  of  one  leg.  If  both  symptoms  are 
present  simultaneously,  the  suspicion  becomes  very  great. 

How  can  we  tell  whether  a  tumour  which  is  found  in  the  pelvis 
really  originates  from  the  pelvic  bones  ?  First,  we  must  be  able  to 
exclude  any  connection  between  it  and  the  pelvic  viscera  by  con- 
sidering the  previous  history  and  the  actually  existing  symptoms. 
For  instance,  if  a  patient  has  for  months  been  losing  blood  with  his 
motions,  and  has  symptoms  of  rectal  stenosis  with  a  growth  adherent 
to  the  sacrum,  he  is  not  the  subject  of  pelvic  tumour,  but  of  a  rectal 
cancer  which  has  contracted  secondary  adhesions  to  the  sacrum. 
Physical  examination,  however,  furnishes  the  clearest  indications. 
Tumours  which  grow  from  the  internal  surface  of  the  pelvic  bones 
are  usually  more  or  less  globular  or  uneven  structures,  connected 
with  the  pelvis  itself  at  a  narrowly  circumscribed  site.  Malignant 
growths  of  the  pelvic  viscera,  once  they  have  become  fixed  to  the 
pelvis,  give  the  impression  of  a  dift\ise  hard  mass,  which  seems  to 
have  been  poured  out  by  the  pelvic  cavity.  Innocent  growths  of  the 
pelvic  viscera  never  become  so  firmly  fixed  to  the  pelvis  as  to  cause 
any  mistake. 

It  might  be  quite  possible  to  mistake  a  pelvic  enchondroma  for  a 
firmly  incarcerated  fibromyoma ;  but  examination  under  anaesthesia 
would  clear  this  up,  because  some  movement  could  then  be  obtained, 
even  with  a  firmly  incarcerated  myoma. 

In  exceptional  cases  a  very  elastic,  tense  bnrrowing  abscess  which 
occupies  the  pelvic  fossa,  or  the  true  pelvis,  may  be  mistaken  for  a 
sarcoma,  especially  if  it  causes  circulatory  disturbances  in   one  leg. 


480         SUKGICAL   DISEASES   OF   THE    PELVIS   AND   SPINAL    COLUMN 

But  such  an  error  would  only  be  pardonable  in  the  absence  of  any 
physical  sign  of  tubercular  disease  of  the  spine  or  pelvic  bones. 

If  a  pelvic  tumour  has  become  large  enough  to  be  grasped  by  the 
'  hand,  or  to  make  special  demands  upon  the  tailor,  there  is  no  longer 
any  difficulty  in  diagnosis.  Tumours  of  a  knotty  structure  within 
the  pelvic  cavity,  especially  in  the  vicinity  of  the  ileo-sacral  joint,  are 
either  osteomata  or  chondromata.  They  may,  in  the  course  of 
years,  grow  as  large  as  a  man's  head,  or  even  larger.  They  are  not 
absolutely  innocent,  because  they  do  sometimes  produce  metastases. 
But,  in  contrast  to  sarcomata,  they  do  not  cause  any  nerve  dis- 
turbances until  late.  On  the  other  hand,  if  we  are  dealing  with  a 
tumour  which  announced  itself  by  pressure  on  nerves,  before  it  could 
be  demonstrated  objectively,  and  whose  symptoms  are  rapidly 
increasing,  there  can  be  no  doubt  about  the  diagnosis  of  "sarcoma." 
If  auscultation  shows  that  there  is  vascular  engorgement  (a  systolic 
murmur),  this  tends  to  confirm  the  diagnosis  of  sarcoma. 

If  the  clinical  diagnosis  should  still  remain  in  doubt,  it  can  be 
settled  by  2i  skiagram,  which  will  also  show  how  much  new  bone 
formation  there  is  in  the  tumour,  its  extent,  or  the  amount  of  bone 
destruction  which  it  has  caused. 

Sarcoma  of  the  acetabulum  presents  a  special  clinical  picture. 
At  first  it  suggests  hip  disease,  but  the  early  onset  and  persistent 
neuralgia,  combined  with  the  absence  of  any  disturbance  in  the 
mobility  of  the  joint,  makes  the  careful  observer  suspect  something 
worse.  Similarly,  sarcoma  of  the  ileo-sacral  region  is  at  first  thought 
to  be  ileo-sacral  tuberculosis.  But  it  is  just  in  this  case  that  ausculta- 
tion enables  an  early  diagnosis  to  be  made  in  some  circumstances. 

In  addition  to  the  pelvic  tumours  hitherto  discussed,  one  should 
mention  the  rare  fibromata  which  grow  from  the  iliac  bone  into  the 
anterior  abdominal  wall.  They  usually  occur  in  the  female  sex  and 
their  clinical  behaviour  approaches  malignancy,  so  that  they  are  very 
suggestive  of  the  well-known  fibromata  of  the  abdominal  integuments. 

In  considering  the  diagnosis  of  pelvic  tumours  one  must  think  of 
fibroma  and  sarcoma  of  the  pelvic  muscles,  which  are  most 
frequently  found  originating  in  the  gluteal  muscles.  As  long  as  they 
are  movable  while  the  muscles  are  relaxed,  they  present  no  difficulty  in 
diagnosis,  and  their  recognition  either  as  a  sarcoma  or  fibroma  is  made 
by  their  form  and  consistence  and  comparative  rapidity  of  growth. 

But  this  is  not  always  possible,  because  some  growths,  which  to 
the  naked  eye  and  microscopically  appear  to  be  fibromata,  are  liable 
to  persistent  recurrence,  and  their  histological  appearances  may  even 
change  to  those  of  sarcoma  in  the  course  of  time. 

If  the  tumour  has  become  adherent  to  bone,  even  the  skiagram 
may  fail  to  indicate  its  site  of  origin. 

The  subject  of  pelvic  tumours  suggests  reference  to  another  class 


CONGENITAL    ABNORMALITIES    IN    THE    SPINAL    COLUMN  481 

of  tumours,  which  usually  escape  adequate  discussion  among 
abdominal  tumours,  because  they  do  not  originate  in   a  viscus. 

These  are  the  tumours  of  the  connective  tissue  of  the  pelvis. 
With  few  ex'ceptions  they  are  dermoids,  which  originate  in  the  pelvic 
connective  tissue,  or  rather  in  the  peri-rectal  tissue,  develop  above  the 
levator  ani,  generally  on  the  left  side,  behind  the  rectum.  If  they 
grow  chiefly  upwards,  they  are  usually  looked  upon  as  ovarian  tumours 
adherent  in  Douglas's  pouch — occurring  as  they  mostly  do  in  the 
female  sex.  If  they  extend  in  a  downward  direction,  they  are  especially 
liable  to  be  taken  for  burrowing  abscesses.  But  their  tense  con- 
sistence, their  well-defined  roundish  shape,  and  the  extreme  displace- 
ment of  adjoining  viscera  should  show  that  they  are  independent 
growths.  Positive  evidence  is  only  furnished  by  exploratory  puncture 
and  operation. 

The  rule  not  to  perform  exploratory  puncture  until  everything  is 
ready  for  operation  applies  here  just  as  well  as  on  other  occasions. 
Dermoids  suppurate  very  easily  and  the  portion  of  the  body  through 
which  the  puncture  has  to  be  made,  does  not  always  permit  of  thorough 
cleansing. 

These  dermoids  are  very  rare  in  males,  but  when  they  do  occur, 
and  the  patient  is  at  the  age  of  prostatic  hypertrophy,  they  usually 
suggest  this  condition. 

For  eighteen  years  a  patient  of  mine  went  about  with  this 
diagnosis.  But  after  he  had  made  a  false  passage  for  himself  and 
even  the  village  midwife  failed  to  pass  a  catheter,  he  came  to  the 
hospital  with  a  cyst  the  size  of  a  man's  head. 

The  same  applies  to  the  very  rare  cysts  of  the  prostate  or  of 
the  retroprostatic  connective  tissue.  Sufferers  from  these  tumours 
do  not  usually  consult  the  surgeon  until  they  get  retention  of  the 
urine,  and  probably  have  a  false  passage  in  addition.  The  diagnosis 
is  first  made  at  the  operation.  In  a  few  cases,  hydatids  have  been 
found  in  this  region. 


CHAPTER  LXXIV. 

CONGENITAL  ABNORMALITIES  IN  THE  SPINAL 

COLUMN. 

If  a  new-born  infant  presents  a  median  swelling  situated  on  the 
spinal  column,  either  slightly  or  not  at  all  movable,  we  should  at  once 
think  of  a  "  spina  bifida."  As  it  is  not  possible  to  distinguish  all  the 
finer  differences  in  this  malformation  by  clinical  signs,  we  shall 
merely  detail  the  main  features  upon  which  the  diagnosis  turns. 

In  some  cases  the  spinal  column,  the  spinal  meninges  and  spinal 
31B 


482        SURGICAL   DISEASES   OF   THE    PELVIS   AXD   SPINAL   COLUMN 

cord  are  completely  cleft,  and  form  a  hood  over  a  shallow  groove,  or 
cause  a  protuberance,  if  a  kyphosis  is  also  present — posterior 
rachischisis  (fig.  208).  Other  malformations,  incompatible  with  life, 
usually  exist  at  the  same  time,  especially  on  the  skull  and  in  the  brain. 


NiglalNlaillt^liJifaiHfilsltell-.     jlli'^NIIaBstasWIiMteteM 


Fig.  207. — Diagrammatic  scheme  of  the  more  important  forms  of  spina  bifida. 

I.  (black)Skin_.     2.  (blue)  Dura.     3.  (red)  Pia.     4-  ^yellow)  Spinal  cord.     P-Pi.  Polar  depressions. 

(a)  Meningocele,     (b)  Myelocystocele.     (c)—(e)  Various  degrees  of  myelo-meningocele. 

(/)  Myelocysto-meningocele. 

In  less  severe  cases  the  spinal  cord  is  also  cleft  and  gives  rise  to 
the  reddish  medullo-vascular  area,  but  the  extent  of  the  fissure  is  less. 
The  "  tumour  "  is  formed  by  an  increased  collection  of  cerebro-spinal 
fluid  in  the  area  of  the  soft  spinal  meninges  on  the  ventral  side  of  the 
hooded  cord— Myelo-meningocele  (fig.  209).     This  form  merges  by 


CONGENITAL    ABNORMALITIES    IN    THE    SPINAL   COLUMN 


483 


intermediate  varieties  into  the  form  wherein  the  spinal  cord  is  closed, 
but  projects  out  of  the  canal,  adherent  to  the  posterior  wall  of  the 
sac.  The  collection  of  fluid  in  this  form  is  also  found  ventrally  in 
the  soft  membranes,  but  is  often  found  at  the  same  time  in  the  dilated 
central  canal — Hydromyelo-meningocele.     The  tumour  has  normal 


Fig.  208. — Posterior  rachischisis.     The  dark  portion  corresponds  to  the  medullo-vascular  area. 


Fig.  209.-— Myelo-meningocele  with  the  superior  depression  clearly  seen  in  the  illustration  (X). 

skin    at  the  periphery,  and  is   covered  at  its  top  with  fine    scar-like 
epidermis  (fig.  210). 

If  the  spinal  cord  is  free  in  the  sac,  and  entirely  covered  by 
arachnoid  membrane,  and  if  the  central  canal  is  considerably  dilated, 
the  case  is  one  of  myelo-cystocele.     If  the  tumour  only  consists  of 


484 


SURGICAL   DISEASES   OF   THE   PELVIS   AND   SPINAL   COLUMN 


protruded  arachnoid,  the  case  is  one  of  pure  meningocele.  The 
dura  takes  no  part  here  either  in  the  composition  of  the  wall  of  the 
sac,  but  stops  short  at  the  level  of  the  gap  in  the  bone. 

How  can  these  various  forms  be  distinguished  clinically  ?  In  the 
first  place  by  the  rest  of  the  child's  condition.  The  more  severe  any 
other  malformation,  the  more  severe  is  the  malformation  of  the  spinal 


Fig.  210. — Myelo-meningocele. 


Fig.  211. — Myelo-meningocele  in  the  region  of  the  conus  terminalis  and  the  cauda  equina. 


cord.  Then  the  condition  of  the  tumour  itself  is  significant.  If  there 
be  a  meduUo-vascular  area  present,  or  if  a  superior  and  inferior  de- 
pression are  found  on  an  epidermal  surface  (fig.  209),  one  may  be 
certain  that  the  spinal  cord  is  cleft.  If  tracts  are  seen  through  the 
sac  wall,  running  from  a  dorsal  thickening  thereof  towards  the  spinal 
column,  they  will  be  recognized  as  nerve-roots,  and  we  may  assume 
that  the  spinal  cord,  whether  cleft  or  not,  is  adherent  to  the  dorsal 


CONGENITAL   ABNORMALITIES    IN   THE    SPINAL   COLUMN 


485 


wall  of  the  sac.  If  such  tracts  are  absent,  the  case  is  either  a  myelo- 
cystocele or  a  meningocele.  But  the  latter  may  also  contain  m  its 
wall  coiled-up  nerve-roots,  running  back  to  the  spinal  canal,  and  thus 
the  diagnosis  may  be  rendered  difficult.  When  the  sac  is  very  large 
the  diagnosis  can  be  facilitated  by  examination  through  transmitted 
light,  and  also  by  the  circumstance  that  a  pure  meningocele  only  occurs 
in  the  sacral  region. 

The  diagnosis  is  most  difficult  when  the  condition  occurs  at  the 
lower  end  of  the  spinal  column,  where  the  conus  terminalis  and  the 
Cauda  equina  may  be  more  or  less  extensively  prolapsed. 

Special  diagnostic  interest  attaches 
to  those  somewhat  infrequent  cases 
wherein  the  cleft  formation  of  the 
spinal  column  and  the  change  in  the 
spinal  cord  or  in  its  cavity  are  so  in- 
definite that  they  are  not  observed 
on  a  superficial  examination.  The 
patient,  however,  seeks  advice  about 
slight  sensory  or  paralytic  symptoms, 
or  occasionally  about  trophic  disturb- 
ances of  the  lower  extremities.  If  the 
symptoms  are  specially  of  a  motor 
character,  one  is  inclined  to  attribute 
them  to  poliomyelitis.  But,  on  an  in- 
spection of  the  back,  we  will  at  once 
be  struck  by  the  well  developed  hairi- 
ness of  an  area,  usually  situated  in  the 
lumbar  region.  The  hairs  are  generally 
arranged  in  a  semicircle,  transversely 
to  the  spinal  column,  with  its  convexity 
downwards.  They  often  become  quite 
long.  Slight  cicatricial  changes  are  fre- 
quently seen  on  the  skin.  On  palpating 
the  spinal  column  a  gap  will  be  noted 
in  the  series  of  vertebral  spines,  at  the 

level  of  the  hairy  patch.  In  this  gap  there  is  an  elastic  swelling, 
which  usually  varies  in  size  from  a  pea  to  a  cherry.  This  constitutes 
the  malformation  known  as  spina  bifida  occulta.  The  swelling, 
Avhich  is  felt,  may  either  be  a  pure  inciiinoocelc  or  a  niyclo-iiieiiingoccle. 
In  some  cases  there  is  not  even  any  nervous  disturbance,  and  the  only 
indication  of  the  malformation  is  the  abnormal  hairiness. 

When  assistant  to  Kocher,  I  saw  a  peasant  lad  in  whom  temporary 
paralytic  symptoms  of  the  lower  limbs  supervened  after  a  blow  on 
the  back.     The  abnormal   hairiness   of  the  lumbar  region  easily  led 


Fig.  212. — Vestigial  tail. 


486         SURGICAL   DISEASES    OF   THE    PELVIS   AND    SPINAL   COLUMX 

to  the  diagnosis  of  spina  bifida  occulta,  which  had  been  injured  by 
the  blow. 

Finally,  the  sacral  region  is  the  site  of  all  possible  congenital 
tumours  :  Fibromata,  angiomata,  lipomata,  sarcomata,  teratomata. 
The  last  include  an  unbroken  series  from  simple  dermoid  cysts  to 
foetal  implantations  and  double  monsters.  These  tumours  are  some- 
times isolated,  at  others  they  are  associated  with  clefts  in  the  spinal 
column  and  spinal  cord.  Sometimes  the  peculiar  character  of  the 
tumour  allows  it  to  be  identified  as  a  fibroma,  lipoma,  dermoid  or 
lymphangioma  ;  but  as  a  rule  one  must  be  content  with  the  diagnosis 
of  congenital  sacro-lumbar  tumour,  and  further  detail  must  be  left 
to  the  microscope.  If  a  dermoid  ruptures  it  gives  rise  to  a  dennoid 
sinus,  already  referred  to  among  the  perinseal  fistulae. 

If  the  sacrum  has  an  appendage  looking  like  a  tail,  it  can  very 
rapidly  be  decided  by  palpation  and  b\'  a  skiagram  whether  the 
structure  onlv  consists  of  soft  tissue — a  false  tail  (lipoma,  fibroma) 
or  is  a  vestigial  tail  without  bone — or  whether  it  contains  a  prolonga- 
tion of  the  spinal  column  and  constitutes  a  real  tail. 

These  vestiges  of  a  "tail  "  period  are  never  found  among  an  entire 
people,  as  has  been  stated.  They  occur  in  individuals  (generally 
males)  of  all  races,  and  vary  from  a  modest  stump  to  a  quite  con- 
spicuous structure,  even  resembling  the  tail  of  a  pig. 


CHAPTER    LXXV. 
LUMBAGO. 

Many  a  diagnosis,  made  with  a  pretence  of  learning,  is  merelv 
the  cover  of  our  ignorance  by  a  classical  term.  This  is  very  often 
true  of  "  lumbago."  A  pain  in  the  lumbar  region,  whose  cause  we  do 
not  know,  is  usually  provided  with  this  name.  We  cannot  apparently 
dispense  with  this  term,  but  we  should  reserve  it  for  a  pain  which 
comes  on  suddenly.  It  is  because  of  the  suddermess  of  the  pain  and 
its  unknown  causation  that  it  is  called  in  German  "  Hexenschusz  " 
(witch's  shot).  This  excludes  a  large  number  of  lumbar  pains  which 
have  nothing  to  do  with  general  lumbago.  Among  these  may  be 
mentioned  as  the  more  important  the  lumbar  pains  of  tabes  and 
paralysis ;  spinal  caries,  renal  stone  and  tuberculosis  ;  chronic  colitis 
(especially  on  the  left  side).  The  lumbar  pains  which  occur  in  acute 
febrile  diseases,  from  influenza  to  small-pox,  are  also  excluded.     Our 


LUMBAGO  487 

discussion  of  the  subject  is,  therefore,  hmited  to  the  two  conceptions — 
rheumatic  lumbago  and  traumatic  lumbago.  Formerly,  the  malady 
was  called  either  rheumatic  or  traumatic,  according  to  personal  taste, 
and  the  nomenclature  had  no  further  significance. 

But  since  insurance  against  accidents  has  become  the  vogue,  there 
is  hardly  any  condition  as  fertile  as  lumbago  as  a  cause  of  actions  for 
damages.  The  blame  for  this  is  not  only  to  be  attributed  to  the 
proverbial  greed  of  the  insured  for  compensation,  but  to  some  extent 
to  the  circumstance  that  the  diagnosis  of  rheumatic  lumbago  is  based 
on  very  insecure  foundations.  Here,  as  elsewhere,  a  condition  which 
we  cannot  explain  is  termed  rheumatic. 

No  one  who  has  ever  suftered  from  lumbago,  and,  therefore,  ob- 
served its  progress  with  accuracy,  can  possibly  believe  that  a  genuine 
inflammation,  be  it  of  rheumatic  or  other  nature,  can  set  in  with  such 
suddenness.  It  always  originates  in  some  slight  and  unexpected  move- 
ment which  the  spinal  column  is  not  prepared  to  meet  by  the  fixation 
of  its  joints.  The  first  consequence  of  this  want  of  fixation  is  that  the 
lateral  articulation  gives  way,  and  the  final  result  is  twisting  of  this 
joint.  There  can  be  no  doubt  that  some  people  suffer  from  an  effect 
of  this  kind  more  than  others  ;  but  this  is  no  evidence  for  the  in- 
flammator}^  origin  of  the  pain.  This  does  not,  however,  dispose  of 
the  contingency  that  pains  may  also  arise  owing  to  rheumatic 
inflammation  of  the  muscles  of  the  back  or  the  lumbar  nerves.  But 
although  these  pains  apparently  begin  without  any  direct  cause,  they 
are  not  sufficiently  sudden  in  their  onset  to  merit  the  designation 
of  lumbago.  The  confusion  between  the  two  conditions  is  due  to  the 
fact  that  the  pains  in  both  are  similarly  localized,  and  are  of  the  same 
subjective  character. 

Thus  we  see  that  there  is  no  sharp  line  of  demarcation  between  the 
ordinary  and  the  traumatic  form  of  lumbago  ;  the  transition  between 
them  is  gradual.  The  actual  strain  which  causes  traumatic  lumbago 
may  be  so  slight  as  to  be  well  within  the  range  of  normal  movements  ; 
the  traumatic  effect  is  simplv  due  to  the  neglect  of  the  individual  to 
fix  the  spine  in  anticipation  of  the  movement. 

As  far  as  the  legal  definition  of  "  accident  "  is  concerned,  the  term 
"  traumatic  lumbago"  should  be  limited  to  injuries  which  result  from 
abnormal  movements  of  the  spine,  such  as  over-bending,  over-strain- 
ing and  excessive  twisting  —  movements  which  are  calculated  to 
produce  distortion,  rupture  of  muscles,  and  tearing  off  of  articular  and 
transverse  processes,  despite  any  amount  of  muscular  fixation. 

In  both  groups  of  cases  the  most  striking  feature  consists  of  the 
muscular  rigidity  of  the  affected  spinal  segment,  generally,  but  not 
always,  the  lumbar  spine.  There  is,  in  addition,  a  certain  amount 
of   localized   pain    on    pressure   and    on  movement ;   but   no  sign  is 


488        SURGICAL   DISEASES   OF   THE    PELVIS   AND   SPINAL   COLUMN 

absolutely  conclusive  in  the  differential  diagnosis.  A  definite  diagnosis 
can  be  more  satisfactorily  based  upon  a  correct  knowledge  of  the 
trauma  on  the  one  hand,  and  the  course  of  the  symptoms  on  the 
other  hand. 

Reliable  information  as  to  the  injury  is  often  unattainable,  because 
the  patient's  statements  are  apt  to  be  exaggerated.  It  is  only  when 
there  has  been  some  evident  cause  (lifting  an  unusually  heavy  weight, 
a  fall,  or  external  violence)  for  a  severe  trauma,  that  we  should  regard 
the  symptoms  which  are  present  as  due  to  an  "accident"  in  the  legal 
sense. 

The  course  of  the  symptoms  furnishes  conclusive  evidence  of  the 
diagnosis,  except  in  the  case  of  insured  patients,  w^ho  have  an  interest 
in  the  prolonged  duration  of  their  malady.  Ordinary  lumbago 
disappears  in  a  few^  days,  but  the  consequences  of  an  extensive  rupture 
of  muscle,  of  a  severe  twMst,  or  the  tearing  off  of  bone,  may  persist  for 
weeks  and  months.  The  diagnosis  is  easy  enough  if  a  good  skiagram 
reveals  a  torn  fragment  of  bone  (fracture  of  a  transverse  process). 
But  in  the  absence  of  this,  or  of  evidence  supplied  by  a  haemorrhagic 
discoloration  of  the  skin,  a  few  days  after  the  accident,  pointing  to 
a  superficial  haematoma,  we  are  bound  to  rely  on  the  bona  fides  of  the 
patient,  and  on  careful  observation  in  hospital. 

The  differential  diagnosis  receives  little  aid  from  inquiries  directed 
to  previous  rheumatic  symptoms,  because  genuine  lumbago  has 
nothing  to  do  with  rheumatism. 

It  is  much  easier  to  recognize  pain  in  the  back  which  follows  a 
direct  contusion.  The  nature  of  the  trauma  is  obvious,  and  we  often 
find  its  immediate  consequences  in  abrasions  and  ecchymosis  of  the 
back. 

Compression  fracture  of  the  spinat  column  can  only  be  mistaken 
for  lumbago  if  the  history  has  not  been  taken  into  account,  and  the 
symptoms  of  compression-fracture  are  unknown  to  the  practitioner. 

It  is  important  to  realize  that  fragments  of  bone  may  be  broken 
off  by  indirect  violence  —  either  through  muscular  contraction,  or 
the  dragging  of  ligaments.  Such  small  fragments  may  be  missed, 
even  on  careful  X-ray  examination,  especially  in  fat  patients. 

Cases  which  show  no  physical  symptoms,  but  wherein  the  subjective 
complaints  are  severe,  constitute  the  most  difficult  of  medico-legal 
problems.  The  patients  delay  their  return  to  work  from  time  to  time, 
extending  over  a  period  of  years,  whereas  they  would  resume  their 
occupation  in  a  few  weeks  or  months  if  they  w^ere  not  insured. 


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INJURIES   OF   THE   SPINAL   COLUMN  489 

CHAPTER  LXXVI. 
INJURIES  OF  THE  SPINAL  COLUMN. 

Injuries  of  the  spinal  column  resemble  those  of  the  skull,  in  that 
their  study  is  dominated  by  the  associated  injury  sustained  by  its 
contents.  In  our  examination,  chief  attention  must  be  devoted  to  this 
consideration. 

Let  us  assume  the  case  of  a  patient  who  has  had  an  injury  to  the 
spine,  generally  through  a  fall  from  a  height,  or  through  something 
having  fallen  on  him,  and  who  then  complains  of  his  back.  But  he 
comes  on  foot,  and  presents  no  change  in  the  shape  of  the  spine, 
nor  any  symptoms  connected  with  the  nervous  system.  He  is 
suffering  either  from  a  contusion  or  distorsion,  or  possibly  from  a 
fracture  of  a  spinal  or  transverse  process,  the  situation  of  which  is 
indicated  by  the  spine  that  is  most  painful  on  pressure.  The  absence 
of  dislocation  is  shown  by  the  normal  position  of  the  spinous 
processes,  by  the  normal  posture  of  the  head  or  back,  and,  as  far  as 
the  upper  cervical  vertebrae  are  concerned,  by  the  absence  of  any 
displacement  which  can  be  felt  through  the  pharynx.  For  further 
details,  see  Chapter  XXV. 

We  only  propose  to  deal  here  with  the  more  serious  injuries  of 
the  spinal  column  in  relation  to  the  spinal  cord. 

I.— METHOD    OF    EXAMINATION. 

Let  us  start  with  a  concrete  case. 

A  man  has  fallen  off  a  scaffold,  and  is  brought  in,  on  an  ambulance. 
We  place  him  in  bed,  being  careful  to  support  his  entire  spme.  Our 
next  task  is  to  make  a  diagnosis,  and  therewith  also  a  prognosis,  with 
the  very  minimum  of  disturbance  to  the  patient. 

(1)  In  order  to  examine  his  power  of  inohiUty,  we  first  ask  him  to 
carry  out  a  few  ordinary  movements.  If  he  lifts  one  leg  after  the 
other,  extends  and  flexes  the  knees  as  directed,  we  may  at  once  be 
reassured  as  to  the  worst  ;  he  has  no  complete  lesion  of  the  spinal 
cord.  But  if  he  does  not  lift  his  feet,  but  contracts  his  thigh  muscles 
with  pain,  we  may  conclude  that  the  nerve-tracts  retain  their  con- 
ductivity, but  that  movement  is  hindered  by  the  pain.  He  may  have 
sustained  a  severe  injury  to  the  spinal  column,  he  may  even  have  a 
fracture  of  both  thighs,  but  the  spinal  cord  has  not  been  crushed 
through.  If  he  is  able  to  raise  one  leg,  while  the  other  remains 
helpless,  he  either  has  a  unilateral  injury  to  the  spinal  cord,  which 
is  very  rare  in  the  case  of  fracture,  or  a  unilateral  contusion  or  com- 
pression of  the  Cauda  equina,  which  is  also  rather  rare.     The  most 


490         SURGICAL   DISEASES   OF   THE    PELVIS   AND   SPINAL   COLUMN 

probable  condition  is  a  fracture  of  the  thigh  or  pelvis,  which  may 
at  once  be  assumed  if  the  patient  can  move  the  foot  and  toes,  while 
he  is  incapable  of  moving  the  thigh. 

The  mobility  of  the  trunk  is  next  examined,  for  which  purpose 
the  method  of  respiration  is  of  great  assistance.  If  the  respiration 
is  purely  of  the  abdominal  type,  i.e.,  diaphragmatic  breathing,  and 
if  thoracic  respiration  is  impossible,  it  means  that  the  intercostal 
muscles  are  paralysed,  and  that  only  the  phrenic  nerve,  which  arises 
from  the  fourth  and  fifth  cervical  segment,  remains  in  action.  The 
injury  is  therefore  severe  and  situated  high  up. 

We  come  next  to  the  mobility  of  the  dipper  extremities.  The 
very  position  of  the  arms  is  significant.  If  they  are  freely  movable 
down  to  the  finger-tips,  and  can  adopt  any  posture  desired,  it  means 
that  the  injury  is  at  any  rate  lower  than  the  first  dorsal  segment.  If 
the  hands  are  half  closed,  the  elbows  flexed,  and  the  forearms  are 
lying  moderately  pronated  on  the  chest,  we  may  conclude  that  the 
injury  is  about  the  level  of  the  seventh  cervical  segment  (fig.  213). 
If  the  arms  are  turned  outwards  and  held  upwards,  with  the  fingers 
semi-flexed,  the  forearms  supine,  and  the  elbows  bent,  the  sixth 
segment  is  injured  (fig.  214).  If  they  lie  immobile,  completely  paralysed 
against  the  trunk,  the  position  of  the  injury  is  at  the  fifth  segment. 
It  cannot  be  any  higher,  because  all  severe  injuries  above  this  level 
cause  paralysis  of  the  phrenic  nerve  and  sudden  death. 

In  the  case  illustrated  in  figs.  213  and  214,  the  autopsy  showed 
that  there  was  a  contusion  between  the  seventh  and  eighth  segments. 
When  the  patient  came  into  hospital  his  posture  was  as  depicted  in 
fig.  213.  On  the  following  day,  when  the  circulatory  disturbance  had 
increased,  he  presented  tiie  posture  shown  in  fig.  214,  and  the  hyper- 
cesthetic  zone  was  displaced  one  segment  higher  up.  In  a  few  days 
there  was  so  much  improvement  that  even  the  eighth  segment 
resumed  its  functions  ;  but  death  from  broncho-pneumonia  followed 
three  weeks  later.  Fig.  216  illustrates  the  spinal  injury  which  had 
occurred  in  this  case. 

(2)  After  this  summary  examination  of  mobility  we  proceed  to  test 
sensation.  If  this  is  preserved  in  the  lower  extremities,  although 
possibly  weakened,  or  lost  to  certain  stimuli,  a  complete  lesion  can  be 
excluded,  even  if  motion  is  entirely  absent.  But  if  it  is  entirely  lost, 
as  is  usually  the  case  when  there  is  total  motor  paralysis  of  the  corre- 
sponding section,  complete  contusion  of  the  spinal  cord  is  very 
probable.  The  level  of  the  injury  can  be  ascertained  from  the  limits 
of  normal  sensation. 

An  area  of  complete  anaesthesia  is  frequently  bounded  by  a  zone 
of  partial  loss  of  sensation  and  a  zone  of  hyperaesthesia. 

This  zone  of  hyper^esthesia  is  not  only  caused  by  irritation  of  the 
nerve-roots,  but  also  by  irritative  changes  within  the  cord  itself,  as  is 


Plate  3. 


Fig.  1. 


Distribution  of  sensory  root-segments  on  the  superficial  skin  (after  Kocher). 

Note:  L.  1  u.  2,  L.  1  u.  2  on  groin  should  appear  as  L.  1—2. 


INJURIES   OF   THE    SPINAL   COLUMN 


491 


proved  by  the  fact   that   this    zone    ascends    in    cases    of   ascending 
myehtis. 

The  examination  of  the  sensation  should  always  be  completed  by 
testing  the  sensations  to  pain  and  temperature.  In  cases  wherein 
there  is  partial  disturbance  of  sensation,  various  kinds  of  sensation 
produce  different  reactions.     Sensibility  to  pain  and  temperature  is 


Fig.  213. — Posture  of  arms  in  a  transverse  lesion  at  the  level  ot  the  seventh 
cervical  segment. 


Fig.  214. — Posture  of  arms  in  a  transverse  lesion  at  the  level  of  the  sixth 
cervical  segment. 


more  greatly  deranged  than  the  sensation  of  taste,  or  the  pain  and 
temperature  sense  may  be  completely  lost,  while  the  sense  of  taste  is 
only  slightly  disturbed. 

(3)  jWe  now  examine  the  condition    of   the   vasomotor   nerves. 

Their  paralysis  is  indicated  by  hyperaemia  of  the  paralysed  extremities, 

by  a  rise  in  the  temperature  of  the  skin,  and  by  congestion  of  the 

corpora  cavernosa  penis 

32 


This  organ  is  usuallv  in  a  state  of  moderate 


492         SURGICAL   DISEASES   OF   THE   PELVIS   AND   SPINAL   COLUMN 

congestion,  and  if  touched,  for  instance  to  pass  a  catheter,  it  may  pass 
into  a  state  of  erection,  and  emission  may  follow, 

(4)  The  condition  of  the  bladder  and  rectum  are  especially  important 
in  regard  to  the  visceral  functions.  In  a  total  lesion  both  these  organs 
are  completely  paralysed.  Paralysis  of  the  bladder  is  shown  by  a 
retention  of  urine,  combined  with  so-called  paradoxical  incontinence. 
The  bladder  is  fully  distended  and  is  recognizable  at  a  first  glance  at 
the  abdominal  wall  ;  it  empties  only  by  overflow  after  the  resistance 
of  the  sphincter  has  been  overcome. 

We  cannot  here  argue  the  question  whether  the  closure  of  the 
sphincter  is  merely  an  action  of  elasticity  (Kocher)  or  whether  it 
depends  upon  some  peripheral  innervation  thereof.  Nor  can  we  here 
go  into  the  details  of  the  diagnosis  of  paradoxical  incontinence. 

If  the  injury  is  not  situated  too  low  down,  the  function  may  in 
time  unconsciously  return  at  periodic  intervals,  as  the  spinal  cord 
resumes  the  automatic  discharge  of  its  duties.  A  condition  comes  on, 
which  Kocher  compares  to  enuresis. 

It  matters  not  whether  we  locate  the  centres  involved  in  the  sacral 
segments  or  in  the  sympathetic,  in  accordance  with  the  views  of 
most  recent  authors  (L.  R.  Miiller).  In  either  case  the  fibres  run 
through  the  conus  medullaris.  If  they  are  torn  through,  a  permanent 
loss  of  voluntary  power  over  the  bladder  and  rectum  follows  in  every 
case. 

The  newer  researches  indicate  that  automatic  action  may  return 
after  a  complete  destruction  of  the  conus,  a  circumstance  untenable 
according  to  the  older  views.  The  onset  of  enuresis  after  paradoxical 
incontinence  has  once  started,  is  especially  found  in  cases  of  partial 
damage  to  the  spinal  cord.  We  know  that  this  may  also  occur  in  dogs 
after  a  complete  lesion,  but  the  subject  has  not  been  sufficiently 
worked  out  in  man. 

On  examining  the  rectum,  it  will  be  found  to  be  full  of  faeces,  as 
long  as  they  are  solid — retentio  alvi.  If  the  rectal  contents  are  liquid, 
they  escape  involuntarily — incontinence  of  faeces. 

Extreme  meteorism,  which  is  a  sign  of  intestinal  paralysis,  is 
another  symptom  of  visceral  derangement.  It  is  a  sign  which  has 
often  suggested  genuine  intestinal  obstruction,  and  which  has  led  to 
the  performance  of  laparotomy. 

We  must  finally  refer  to  disturbances  in  the  Innervation  of  the  pupils. 
If  reflex  fixation  of  the  pupil  be  present  with  miosis,  it  follows  that 
the  pupillo-dilator  fibres  are  interrupted  somewhere  in  their  course 
through  the  spinal  cord,  and  that  therefore  the  lesion  must  be  above 
the  first  dorsal  segment,  in  the  roots  of  which  these  fibres  leave  the 
cord. 

(5)  There  now  remains  the  important  matter  of  the  examination  of 
the  skin  and  tendon  reflexes. 


INJURIES   OF   THE   SPINAL   COLUMN  493 

In  a  complete  lesion  the  superficial  or  skin  reflexes  are  usually 
lost,  but  they  return  again.  Kocher  has,  however,  pointed  out  that 
the  genital  reflexes  are  not  lost,  viz.,  the  erection  reflex,  and  unilateral 
contraction  of  the  lower  abdominal  muscles  on  squeezing  the  testicle 
(Kocher's  testicular  reflex).  The  tendon  reflexes,  especially  the 
patellar  reflex,  are  of  greater  importance.  If  it  is  absent,  it  signifies  a 
very  severe  injury,  generally  a  complete  lesion.  If  it  remains  per- 
manently absent  there  is  no  doubt  at  all  about  this  (Bastian-Brun's 
law).  It  may  also  be  absent  in  partial  lesions.  It  does  not  then 
usually  take  more  than  a  few  hours  for  it  to  return,  though  I  have 
seen  the  absence  persist  for  days,  in  rare  cases.  If,  on  the  other  hand, 
the  patellar  reflex  remains  after  an  injury  to  the  spinal  cord,  or  is 
actually  increased,  we  may  safely  exclude  a  complete  lesion,  even  if 
the  other  symptoms  are  severe. 

These  remarks  only  apply  to  human  beings  and  to  sudden 
traumatic  complete  laceration.  In  dogs,  the  tendon  reflexes  may  also, 
in  such  a  case,  return  after  a  short  delay.  In  man,  the  reflexes  are 
either  retained  or  even  increased,  in  cases  of  gradual  interference 
with  the  cord,  through  tumours  or  inflammatory  processes.  On  the 
other  hand,  there  is  no  record  of  a  case  wherein  the  tendon  reflexes 
had  previously  been  normal,  and  in  which  they  were  either  retained 
or  increased  after  the  spinal  cord  has  been  suddenly  torn  through. 
I  will  not  dispute  the  possibility  of  a  partial  return  of  the  tendon 
reflexes  months  after  a  complete  traumatic  division  of  the  cord,  even 
in  man,  but  I  have  never  seen  such  a  case ;  but  this  does  not 
invalidate  the  diagnostic  importance  of  Bastian-Brun's  law. 


II.— DIAGNOSIS  OF  THE  NATURE,  DEGREE  AND 
POSITION  OF  THE  INJURY. 

Our  examination  now  puts  us  in  a  position  to  answer  the  two 
important  questions  to  which  every  spinal  injury  gives  rise,  namely  : — 

(i)   Is  the  injury  complete  or  partial  ? 

(2)  At  which  level  is  it  situated,  and  what  conclusions  may  we 
draw  from  the  injury  to  the  cord,  in  regard  to  the  injury  to  the 
spinal  column  ? 

(A)  THE  DEGREE  AND  THE  NATURE  OF  THE  SPINAL 
CORD  INJURY. 

We  have  first  to  decide  whether  the  injury  has  caused  complete  or 
partial  division  of  the  cord.  We  may  summarize  the  indications 
already  referred  to  in  the  following  way  : — 

We  may  assume  a  complete  lesion  wJien  there  is  persistent,  sym- 
metrical, total,  flaccid  motor  paralysis,  with  sensory  paralysis  in  the  corre- 
sponding area,  and  when  the  tendon  reflexes  are  lost  for  a  considerable 


494        SURGICAL   DISEASES   OF   THE    PELVIS   AND   SPINAL   COLUMN 

time,  and  when  the  bladder  and  rectum  are  paralysed,  in  the  absence, 
Jiowever,  of  all  motor  and  sensory  irritative  symptoms  in  the  paralysed 
regions. 

We  tnust,  on  the  other  hand,  assume  a  partial  lesion  when  signs  of 
voluntary  innervation  and  of  sensation  are  present  beloiv  the  site  of 
injury ;  ivlien,  in  their  absence,  the  patellar  reflex  is  retained  or  is  soon 
restored ;  when  motor  or  sensory  symptoms  of  irritation  appear  in  the 
paralysed  regions,  in  the  first  few  days  after  the  accident,  and  when 
bladder  and  rectum  still  act  volnutarily,  or  at  any  rate  wlien  their 
automatic  function  sets  in  early. 

A  partial  lesion  can  naturally  occur  in  various  degrees  and  forms. 

Hemi-section  of  the  cord  produces  a  somewhat  typical  form  of 
lesion  with  a  symptom-complex  to  which  the  name  of  Brown- 
Sequard's  paralysis  has  been  given.  The  more  complete  and  the 
sharper  the  hemi-section,  the  more  accurately  do  the  symptoms 
correspond  to  the  following  scheme,  viz.  : — 

On  the  side  of  the  injury  :— 

(a)  Motor-paralysis,  in  the  form  of  paralysis  of  a  pyramidal  tract, 
with  a  localized  zone  of  cornual  paralysis  at  the  upper  border. 

(b)  Vasomotor  paralysis. 

(c)  Hypercssthesia  for  all  forms  of  sensation. 

(d)  Loss  of  the  muscle  sense,  which  is  no  longer  generally 
recognized  as  a  separate  function  (deep  sensibility). 

(6^)  Increase  of  the  tendon  reflexes  in  consequence  of  the  break 
in  the  conducting  path.    ~ 

(/)  In  the  cervical  cord  ;  paralysis  of  the  oculo-pupillary 
fibres. 

On  the  uninjured  side  we  find  : — 

Sensory  paralysis  either  for  all  or  for  certain  forms  of  sensation. 

It  would  be  of  great  interest  from  the  point  of  view  of  treatment, 
if  we  could  go  further  and  distinguish  between  contusion  and  com- 
pression. The  present  state  of  our  knowledge,  however,  does  not 
allow  us  to  do  so. 

We  might  very  well  indirectly  conclude  that  contusion  had  taken 
place  if  we  can  demonstrate  displacement  of  a  vertebra.  If  we 
have  concluded,  from  the  absence  of  this  sign  and  from  the  slightness 
of  the  symptoms,  that  the  case  is  one  of  mere  compression  by  a 
hcematoma  (always  a  very  uncertain  diagnosis),  then  the  presence 
of  much  blood  in  the  cerebrospinal  fluid,  drawn  off  by  lumbar 
puncture,  would  suggest  that  the  h?ematoma  is  situated  inside  the 
dura.  This  intradural  haemorrhage  is  also  distinguished  from 
haemorrhage  inside  the  the  cord  (haematomyelia)  by  the  predomin- 
ance of  symptoms  of  irritation.  (Paraesthesia,  increase  in  the  muscle 
tone  and  of  the  reflexes.) 

In  haematomyelia  the  paralytic  symptoms  predominate  ;  if  the 
haemorrhage  is  in  the  cervical  cord,  the  disturbance  is  most  marked 
in  the  lower  extremities.     The  sensations  of  pain  and  of  temperature 


INJURIES   OF   THE   SPINAL   COLUMN  495 

undergo  most  disturbance,  just  as  in  syringomyelia.  Very  circum- 
scribed haemorrhages  lead  to  diplegia,  and  as  they  are  most  frequent 
in  the  cervical  cord,  the  diplegia  is  of  the  brachial  type.  Finally, 
it  should  be  noted  that  such  haemorrhages  in  the  cord  (especially  in 
the  grey  substance)  may  occur  without  any  injury  to  the  spinal 
column,  as  they  have  been  observed  to  follow  a  temporary  overstrain 
of  the  spine  and  consequent  dragging  on  the  cord.  These  have  always 
been  situated  in  the  cervical  or  in  the  lumbar  cord. 


(B)  THE  POSITION  OF  THE  SPINAL  CORD  INJURY. 

(The  Diagnosis  of  the  Level  of  the  Lesion.) 

The  level  of  the  lesion  may  be  ascertained  by  co-ordinating  the 
results  of  the  tests  for  motion  and  sensation.  We  need  not  enter 
into  details  because  they  are  clear,  from  Plates  I,  II,  and  III,  taken  from 
Kocher's  work,  which  are  diagrammatic  representations  of  the  dis- 
tribution of  motion  and  sensation  in  accordance  with  the  individual 
segments,  and  also  from  the  adjoining  diagram  (fig.  215).  It  is  only 
necessary  here  to  add  a  few  general  remarks. 

(i)  In  injuries  of  the  cervical  cord  the  posture  of  the  arms  tells  us 
at  once  the  approximate  level  of  the  injury,  as  previously  stated.  We 
must,  however,  not  be  content  with  the  demonstration  of  these  postures, 
but  must  carefully  examine  power  of  movement. 

In  comparing  what  we  find  with  the  plates,  we  must  remember 
that  motor  symptoms  are  not  all  due  to  the  same  cause.  They  may 
be  caused  :  — 

(a)  By  compression,  or  the  tearing  through  of  the  pyramidal 
tracts. 

(6)  By  destruction  of  the  anterior  cornua  and  of  the  intra- 
medullary roots. 

(c)  By  damage  to  the  roots  after  their  exit  from  the  spinal  cord  or 
from  the  dural  sheath. 

According  to  the  rules  of  spinal  cord  pathology,  the  first  form 
should  cause  spastic  paralysis,  without  the  reaction  of  degeneration, 
the  other  two  should  cause  flaccid  paralysis  with  the  reaction  of 
degeneration.  But,  as  a  matter  of  fact,  all  paralyses  are  flaccid  at  first, 
and  even  when  due  to  a  break  in  the  pyramidal  tract,  the  spasticity 
does  not  come  on  for  some  considerable  time,  indeed  until  the  lower 
spinal  segment  has  regained  its  automatism.  But,  on  the  other  hand, 
the  reaction  of  degeneration  enables  us  to  distinguish  between 
paralysis  due  to  a  break  in  the  pyramidal  tract  and  paralysis  due  to  a 
lesion  in  the  cornua  or  in  the  roots,  at  any  rate  after  a  few  days.  The 
nuclei  are,  however,  not  accurately  divisible  into  segments,  so  that 
the  nerve  supply  of  one  muscle  may  be  derived  from  several 
segments.  The  reaction  of  degeneration,  however,  only  manifests 
itself  when  the  whole  of  the  nucleus  or  all  the  roots  are  destroyed. 
If    a    transverse    lesion,   for   example,    hits   off   the  upper   end   of   a 

32A 


INJURIES  OFTHE  SPINE 
MOTION 

5mall  cervical  muscles 

_5c_a£ujar  rnuscles uo 

Sterno  -  mastoid,  Tra  pezi  us 


SENSATION 


Fig.  211;. 


INJURIES   OF   THE   SPINAL   COLUMN  497 

nucleus,  only  a  small  part  of  the  muscle  undergoes  trophic  change. 
The  rest  of  the  muscle  is  paralysed  owing  to  the  break  in  the 
pyramidal  tract,  and  we  must  not  expect  the  reaction  of  degenera- 
tion. Patients  with  severe  damage  to  the  cervical  cord  have  generally 
succumbed  before  the  reaction  of  ,  degeneration  has  had  time  to 
develop. 

We  are  apt  to  diagnose  the  lesion  in  too  low  a  segment,  owing 
to  the  fact  that  auxiliary  innervation  may  be  derived  from  the  segment 
next  highest  to  the  one  affected.  On  the  olher  hand,  the  upper  limit 
of  the  symptoms  may,  in  exceptional  cases,  be  due  to  an  ascending 
traumatic  myelitis,  or  to  some  transitory  distant  cause,  and  so  we  may 
diagnose  the  lesion  higher  up  than  it  really  is.  It  is,  therefore,  of  the 
greatest  importance  to  make  repeated  examinations,  comparing  the  one 
with  the  other  before  deciding  as  to  the  level  of  the  injury. 

In  general,  we  may  say  that  the  shoulders  and  the  elbows  are 
supplied  from  the  fifth  and  sixth  segments,  the  wrist  from  the  seventh, 
the  long  muscles  of  the  fingers  from  the  eighth,  the  small  muscles  of 
the  hand  and  fingers  from  the  first  dorsal  segment,  which  is  function- 
ally connected  with  the  eighth  cervical. 

We  examine  sensation  on  the  arms,  because  the  neck  and  shoulder, 
as  well  as  the  thorax  as  high  as  the  level  of  the  second  rib,  are  supplied 
by  the  fourth  segment  (supraclavicular  nerves).  The  radial  side  of  the 
arm  corresponds  to  the  fifth  cervical  segment,  the  ulnar  side  to  the  first 
dorsal  segment.  The  areas  corresponding  to  the  other  segments  lie 
between  them  in  the  form  of  bands.  As  the  segments  also  coalesce 
in  regard  to  sensation,  we  must  onl}^  make  use  of  complete  loss 
thereof,  for  the  purpose  of  focal  diagnoses,  at  any  rate  in  total 
lesions. 

Kocher's  Plate  III  is  constructed  on  this  assumption  ;  for  instance, 
the  upper  border  of  the  sixth  segment  does  not  indicate  the  limit  up 
to  which  its  fibres  themselves  reach,  but  it  represents  the  limit  to  which 
the  auxiliary  fibres  of  the  fifth  segment  reach  ;  in  other  words,  it  is  the 
upper  limit  of  total  anaesthesia  caused  by  destruction  of  the  sixth 
segment.  When  the  lesion  is  partial  we  define  its  level  by  the  zone  in 
which  the  disturbance  is  most  pronounced  and  in  which  the  most 
forms  of  sensation  are  lost,  that  is  to  say,  we  do  not  take  into  con- 
sideration the  sensibility  to  touch  only,  but  also  to  pain  and 
temperature. 

Symptoms  of  irritation  are  of  more  importance  here  than  in  the 
case  of  motor  disturbances.  They  do  not,  in  cases  of  a  total  lesion, 
indicate  the  actual  segment  which  is  injured,  but  the  one  directly 
above  it,  sometimes  even  one  higher.  This  is  the  case  if  auxiliary 
fibres  are  irritated  in  the  area  corresponding  to  the  next  higher 
segment.  In  partial  lesions  of  the  cord,  the  irritative  symptoms  may 
also  correspond  to  the  injured  segment  itself.  We  may  assume  this  to 
be  the  case,  when  irritative  and  paralytic  symptoms  are  combined  in 
the  same  zone,  and  when  there  is  no  complete  paralysis  below  it. 
32B 


498         SURGICAL   DISEASES   OF   THE    PELVIS   AND   SPIXAL   COLUMN 

Ascending  myelitis  may  affect  sensation  just  as  it  does  motion, 
and  therefore  give  rise  to  the  diagnosis  of  a  segment,  which  is  one  too 
high. 

(2)  In  injury  to  the  cord  in  the  dorsal  region,  the  motor  conditions 
are  not  of  great  vahie  for  focal  diagnosis,  because  neither  the  nerve 
supply  of  the  muscles  of  the  back,  nor  that  of  the  intercostals  can  be 
applied  to  the  purpose.  The  nerve  supply  to  the  abdominal  muscles, 
derived  from  the  seventh  to  twelfth  dorsal  segments,  are  equally 
useless  for  this  purpose. 

The  sensory  nerve  supply  is,  therefore,  of  more  importance.  As 
previously  remarked,  the  supraclavicular  nerves,  derived  from  the 
fourth  cervical  segment,  supply  sensation  as  far  as  the  second  intercostal 
space.  Next  to  this  lies  the  area  of  the  second  dorsal  segment,  with 
its  border  transverse,  and  not  parallel  to  the  ribs,  and  the  other 
dorsal  segments  follow.  These  areas  lie  lower  than  the  point  of 
exit  of  the  corresponding  nerves  in  the  upper  part  of  the  chest  to  the 
extent  of  three  spinous  processes,  and  lower  down  to  the  extent 
of  four  or  five. 

Kocher  has  suggested  a  very  convenient  indication,  according  to 
which  the  upper  border  of  insensibility  corresponds  to  the  lowest 
anterior  point  of  the  intercostal  space  in  which  the  injured  nerve 
runs.  From  this  point  the  border  line  runs,  not  obliquelv,  but  rather 
horizontally  backwards.  The  areas  widen  out  in  the  neighbourhood 
of  the  linea  alba,  because  the  area  of  the  twelfth  intercostal  nerve 
reaches  as  low  down  as  the  symphysis. 

What  has  been  said  of  the  cervical  cord,  in  regard  to  the  limitation 
of  the  areas,  applies  here  also. 

The  behaviour  of  the  pupils  will  show  whether  the  first  or  the 
second  dorsal  segment  has  been  destroyed,  as  previously  stated. 

(3)  As  the  segments  of  the  Iinnbo-sacral  cord  are  very  small  in 
extent,  we  may  expect  several  to  be  involved  in  one  injury.  The 
cornual  lesion  predominates  over  the  paral^^sis  of  the  pyramidal  tract, 
and  the  return  of  automatic  activity  to  the  cord  below  the  site  of 
injury  is  compromised  by  the  great  extent  to  which  it  is  injured. 
The  shortest  reflex  arcs  are  very  liable  to  be  directly  interrupted, 
so  that  some  reflexes  do  not  return,  even  after  prolonged  delay.  The 
diagnosis  is  also  rendered  difiicult  owing  to  the  course  of  the  nerve 
trunks  being  more  oblique  than  in  the  other  parts  of  the  spinal  cord, 
and  therefore  more  subject  to  extensive  contusion.  It  may  even 
be  difificult,  under  these  circumstances,  to  decide  whether  there  is  a 
genuine  lesion  of  the  cord,  or  merely  a  contusion  of  the  cauda 
equina. 

In  actual  practice,  the  following  may  be  taken  as  a  guide:  if,  in 
a  case  of  complete  motor  and  sensory  paralysis,  some  reflexes  are 
still  obtainable,  the  condition  is  certainly  one  of  cord  lesion ;  a 
comparison  of  the  physical  features  found  on  examination  with  the 


INJURIES   OF   THE   SPINAL   COLUMN  499 

appropriate  plates,  will  show  the  precise  position  of  the  lesion.  If  no 
reflexes  are  obtainable,  we  may  be  in  doubt,  especially  for  the  first 
day  or  two,  whether  the  cord  or  the  cauda  equina  has  been  injured. 
In  such  a  case  the  onset  of  irritative  symptoms,  "paraplegia  dolorosa," 
would  point  to  compression  of  tJie  cauda  equina.  If,  later  on,  some 
reflexes  return,  despite  the  persistence  of  the  paralysis,  it  shows  that 
the  cord  has,  at  any  rate,  participated  in  the  injury.  If  the  reflexes 
are  persistently  absent,  the  onset  of  the  reaction  of  degeneration  in 
all  the  paralysed  muscles,  strongly  suggests  contusion  of  the  cauda 
equina,  whereas  the  persistence  of  electrical  irritability  in  some  of 
the  paralysed  muscles  would  indicate  that  the  cord  is  also  injured. 
Subsidence  of  the  paralysis  and  a  simultaneous  return  of  the  reflexes 
naturally  also  occurs  in  contusion  of  the  cauda  equina.  The  position  of 
tlie  injury  in  tlie  spinal  column  is  obviously  of  significance.  If  it  can  be 
shown  that  it  is  situated  above  the  first  lumbar  vertebra,  it  is  con- 
clusive of  injury  to  the  cord;  if  the  injured  vertebra  is  much  lower 
down,  it  is  equally  conclusive  of  injury  to  the  cauda  equina.  But 
it  is  very  often  impossible  to  tell  which  is  the  injured  vertebra,  or  the 
indications  are  too  indefinite  to  be  relied  upon. 

A  young  man,  who  was  hurt  in  a  motor-car  accident,  sustained, 
among  other  injuries,  a  contusion  in  the  sacral  region.  He  exhibited 
for  a  few  weeks  nervous  disturbances,  which,  from  his  description, 
appeared  to  be  due  to  a  lesion  of  the  cauda  equina.  Examination, 
however,  showed  that  the  only  trace  of  his  accident  consisted  of  great 
increase  of  the  tendon  reflexes,  especially  on  one  side.  This  was 
conclusive  of  injury  to  the  cord. 

Many  types  of  paralysis  have  been  described  in  connection  with 
the  lumbo-sacral  cord,  as  for  the  cervical  cord — almost  as  many  types 
as  segments.  It  is  quite  unnecessary  to  enumerate  them,  because 
they  can  all  be  inferred  by  co-relating  the  motor  and  sensory  nerve 
areas  as  depicted  in  the  plates.  They  are  not  so  striking  to  the 
observer  as  the  types  of  cervical  cord  injury,  recognized  by  the 
peculiar  postures  of  the  extremities. 


(C)   RELATIONS  BETWEEN  THE  INJURY  TO  THE  CORD 
AND  THE  VERTEBRy^. 

Just  as  clinical  examination  and  skiagraphy  often  enable  us  to 
diagnose  the  level  of  a  lesion  in  the  cord,  so,  on  the  other  hand, 
are  we  able,  in  some  cases,  to  diagnose  the  segment  affected  by  the 
displaced  vertebra.     A  few  anatomical  data  are  necessary  for  this. 

We  begin  with  the  cervical  vertebra'.  The  cervical  cord  has  eight 
segments,  and  as  the  first  dorsal  segment  lies  behind  the  last  cervical 
vertebra,  if  follows  that  the  seven  cervical  vertebrae  correspond  to  nine 
segments.  The  segment  in  the  middle  of  the  cervical  cord  must  be 
one  higher  in  number  than  the  corresponding  vertebra.  At  the  end 
of  the  cervical  vertebrae,  the  number  of  the  segment  is  one  and  a  half 
to  tvv'o  higher  ;  thus  behind  the  6th  vertebra,  we  have,  not  the  6th 


500        SURGICAL    DISEASES   OF   THE    PELVIS   AND    SPINAL   COLUMN 


Fig.  2i6. — Dislocation-compression-fracture  in 
the  dislocated  position.  (From  a  post-nioriein  pre- 
paration). Tlie  7th  cervical  vertebra  is  compressed, 
and  the  6th  is  displaced  slightly  forwards.  The 
5th  vertebral  spine  overrides  the  6th.  The  articular 
processes  of  the  6th  and  7th  are  not  interlocked, 
but  their  extremities  are  in  contact  with  each  other. 


Wfft*^ 


Fig.  217.— Complete  bilateral  dislocation  between  the  2nd  and 
3rd  lumbar  vertebra;.  Interlocking  of  the  articular  processes 
a  and  b.  Indication  of  an  oblique  fracture  at  the  anterior  border 
of  the  3rd  lumbar  vertebra.      (From  z. post-mortem  preparation.) 


segment,  but  the  yth  and  a 
portion  of  the  8th,  and  be- 
hind the  8th  vertebra  there 
are  the  remainder  of  the 
8th  and  the  whole  of  the  ist 
dorsal  segment. 

In  the  dorsal  vertebra', 
eleven  segments  (2-12)  are 
divided  between  the  first  ten 
vertebrae.  In  the  upper  of 
these  vertebras  the  number 
of  the  segment  is  one  higher 
than  that  of  the  correspond- 
ing vertebra,  whereas  in  the 
lower  vertebrae  the  difference 
is  two.  Thus  the  3rd  seg- 
ment lies  behind  the  2nd 
dorsal  vertebra,  while  the 
12th  segment  is  mainly  be- 
hind the  loth  vertebra. 

The  whole  of  the  linuhar 
and  sacral  segments  lie  be- 
hind the  nth  and 
12th  dorsal  and 
the  ist  lumbar  ver- 
tebrae. It  is  not 
practicable  to  sep- 
arate these  seg- 
ments anatomic- 
ally. We  may, 
however,  say  that 
the  upper  edge  of 
the  12th  dorsal 
vertebra  corre- 
sponds to  the 
2nd  lumbar  seg- 
ment, and  that  the 
upper  edge  of  the 
ist  lumbar  ver- 
tebra corresponds 
to  the  5th  lumbar 
segment. 

If  we  apply  on 
the  basis  of  these 


INJURIES   OF   THE   SPINAL   COLUMN 


501 


statements  and  the  table  in  fig.  215,  the  existing  nerve  disturbances 
to  the  indirect  diagnosis  of  the  injured  vertebra,  we  must  remember 
that  the  cord  is  not  contused  by  the  anteriorly  displaced  vertebra,  but 
by  the  upper  edge  of  the  one  immediately  below  (fig.  217).  Sometimes 
the  cord  is  contused  by  a  small  piece  of  the  upper  displaced  vertebra, 
resting  on  the  posterior  edge  of  the  vertebra  below  (fig.  220).  In 
cases  of  compression-fracture  the  cord  may  be  damaged  by  a  fragment 
of  the  vertebral  body,  forced  into  the  spinal  canal. 

If  we  wish  to  verify  the  diagnosis  based  upon  the  nerve  symptoms 
and  obtain  a  direct 
detennination  of  the 
displaced  or  injured 
vertebra,  we  must  be 
careful  to  move  the 
patient  with  the  very 
greatest  caution. 

Anticipating  what 
will  be  said  later, 
we  will  observe  here 
only  that  the  spine  of 
a  vertebra  displaced 
forwards,  either  by 
dislocation  or  by 
fracture  -  dislocation, 
is  depressed,  and 
generally  turned 
somew^hat  upwards, 
and  that  it,  therefore, 
limits  anteriorly  the 
gap  found  in  the 
row  of  spinous  pro- 
cesses. If,  on  the 
other  hand,  one  in- 
dividual vertebra  is 
compressed,  its  spine 
projects  somewhat 
backwards  as  the 
summit  of  a  more  or  less  pronounced  angular  kink  in  the  spinal  column. 
If  several  vertebras  are  compressed,  their  spines  will  form  a  round 
curvature. 

(D)  THE  FORM  OF  THE  SPINAL  INJURY. 

It  is  of  therapeutic  and  prognostic  importance  to  recognize  the 
form  of  the  spinal  injury.  If  this  is  not  elucidated  by  a  skiagram,  w^e 
must  depend  upon  the  indirect  evidence  furnished  by  the  spinal  cord 
injury,  or  by  the  signs  found  in  the  spinal  column. 

We  may  distinguish,   in    accordance  with    old    custom,   between 


Fig.  218. — Compression-fracture  of  2nd  lumbar  vertebra. 
The  vertebra  lower  than  the  adjoining  ones.  Intervertebral 
disc  narrower  than  normal. 


502        SURGICAL   DISEASES   OF   THE   PELVIS    AND   SPINAL   COLUMN 

dislocations  and  fractures,  at  any  rate  on  paper.  The  dislocations  are 
either  unilateral  (rotation-dislocation),  or  bilateral  (total  dislocation). 
Thev  are  incomplete  when  the  articular  processes  override  each  other 
(fig.  216)  and  complete  when  the  particular  processes  are  interlocked 
(fig.  217).  Fractures  conctvn  either  the  arch  and  processes  only,  or 
the  body  itself.  The  latter,  which  claim  our  main  interest  here,  are 
either  compression-fractures  (figs.  216,  219,  221),  or  oblique  fractures, 
i.e.,  fractures  which  traverse  the  body  of  the  vertebra  obliquely,  from 


Fig.  219. — Oblique  fracture-dislocation.  (From 
a  pust-viortem  preparation.) 


Fig.  220. — Compression-fracture-dislocation,  with  dis 
placement  of  upper  section,  backwards.  {Post-moriet. 
preparation.) 


above  and  behhid  to  below  and  forwards.  These  oblique  fractures 
sometimes  involve  two  neighbouring  vertebrce.  It  is  only  rarely 
that  the  line  of  an  oblique  fracture  ascends  from  one  side  to 
the  other.  There  are  finally  some  fractures,  intermediate  between 
oblique  fractures  and  compression  fractures,  in  that  the  wedge-shaped 
fragments  exhibit  signs  of  shattering  by  pressure,  in  addition  to  their 
wedge-like  form.  The  right  to  distinguish  between  oblique  and  com-' 
pression  fractures  follows  from  the  different  ways  in  which  the  two 


INJURIES   OF   THE    SPINAL   COLUMN 


5^3 


injuries  occur.  In  compression-fracture  the  force  acts  in  the  axis  of 
the  spinal  column  ;  in  oblique  fractures  it  acts  more  or  less  vertically 
to  it.  The  more  these  two  forces  co-operate  the  more  mixed  is  the 
type  of  the  fracture.  The  more  the  force  acts  perpendicularly  to  the 
spinal  column,  the  more  displacement  takes  place  between  the  two 
vertebrae,  and  the  final  effect  of  the  injury  is  to  resemble  a  dislocation. 
If  the  displacement  has  produced  complete  dislocation  we  describe 
it  as  a  total  dislocation  fracture,  which  may  be  either  an  oblique  fracture 
dislocation,  or  a  compression-fracture  dislocation,  according  to  the 
degree  and  form  of  the  shattering. 

How  much  can  we  recognize  clinically  of  all  this  ?  The  main 
question  which  concerns  the  future  of  the  patient  is  this  :  Is  he  suffering 
from  an  injury  without  displacement  and  therefore  generally  without 
severe  contusion  of  the  cord,  or  from  an  injury  with  displacement  and 
therefore  with  more  or  less  severe  contusion  thereof  ?     Compression- 


FlG.  221. — Compression-fracture  ot  the  lower  dorsal  vertebrae  (X).  Very  slight  cord 
symptoms.  Simultaneous  localized  compression-fracture  of  3rd  dorsal  vertebra  and  transverse 
fracture  of  the  sternum. 

fractures  and  fractures  of  the  arch  belong  to  the  first  group,  total 
dislocations  and  total  dislocation-fractures  in  their  various  forms 
belong  to  the  second  group — injuries  which  we  may  class  together  as 
total  displacements. 


(1)   Fractures  of  the  Spinous  and  Transverse  Processes. 

Fracture  of  a  spinous  process  is  caused  by  a  direct  localized  force, 
and  the  objective  signs  consist  of  a  circumscribed  persistent  pain  on 
pressure  over  the  spinous  process,  striking  preternatural  mobility 
thereof,  and  the  subsequent  onset  of  ecchymosis.     As  a  rule,  however. 


504        SURGICAL   DISEASES   OF   THE   PELVIS   AND   SPINAL   COLUMN 

a  positive  diagnosis  can  only  be  made  from  a  skiagram,  taken  from 
the  side. 

It  is  more  difficult  to  recognize  fracture  of  a  transverse  process. 
This  injury  may  result  from  direct  violence  or  from  muscular  action. 
It  may  be  suspected  from  the  presence  of  a  persistent  and  pronounced 
pain  on  one  side,  on  lateral  flexion  of  the  spinal  column,  and  from 
pain  on  pressure  on  one  side,  while  the  corresponding  spinous  process 
is  not  painful.  A  positive  diagnosis  can  only  be  made  after  an  X-ray 
examination.  This  injury  is  practically  confined  to  the  lumbar 
vertebrae,  and  often  causes  prolonged  discomfort.  The  actual  pain 
may  not  be  very  great,  but  it  suffices  to  incapacitate  people  from 
employment  for  many  months,  especially  when  there  is  no  ardent 
zeal  for  work. 

Fracture  of  a  transverse  process  in  the  neck  is  directly  combined 
with  fracture  of  the  articular  process.  The  mechanism  of  rotation- 
dislocation  usually  comes  into  play,  but  the  interlocking  of  the 
articular  processes  is  prevented  by  the  fracture  of  one  of  them,  so 
that  the  position  of  rotation  is  not  fully  developed.  Under  these 
circumstances  the  diagnosis  is  very  difficult.  The  symptoms  are  too 
severe  for  a  simple  sprain,  and  insufficiently  distinct  for  a  unilateral 
dislocation.  The  differential  diagnosis  is  only  possible  by  X-ray 
examination. 

We  thus  see  that  opportunities  for  wrong  diagnoses  are  very 
abundant,  unless  X-ray  examination  is  employed,  especially  when  the 
■patients  are  workmen  insured  against  accidents.  Formerly,  if  the 
symptoms  did  not  coincide  with  the  physical  signs,  some  observers 
called  the  patient  a  malingerer,  others  of  a  more  kindly  disposition 
called  him  the  subject  of  a  "  traumatic  neurosis."  But  it  has  become 
evident  that  pure  malingering  is  rare,  and  that  the  term  traumatic 
neurosis  ought  not  to  be  applied  unless  the  accident  has  produced 
serious  results,  accompanied  by  psychical  damage.  The  view  now 
taken  of  the  cases  where  there  is  no  anatomical  injur}^,  is  that  it  is 
neither  a  matter  of  malingering  nor  of  traumatic  neurosis,  but  rather 
of — often  unconscious — exaggeration.  This  is  a  much  more  probable 
view,  and,  psychologically  more  intelligible. 

The  main  point,  however,  is  that  the  patients  must  be  thoroughly 
examined,  and  if  the  skiagram  is  doubtful,  additional  pictures  must  be 
taken  in  various  positions  until  the  case  becomes  clear. 

(2)  Fracture  of  the  Vertebral  Arch. 

If  there  are  no  spinal  cord  symptoms,  there  is  every  probability 
that  the  arch  only  has  been  fractured,  but  it  does  not  necessarily 
exclude  fracture  of  the  spinous  process.  In  the  presence  of  cord 
symptoms  we  should  think  of  fracture  of  an  arch,  if  the  spinal  column 
has  not  lost  its  supporting  power,  and  if  axial  pressure  is  only  slightly. 


INJURIES   OF   THE   SPINAL   COLUMN 


505 


or  not  at  all  painful,  and  when  these  symptoms  are  combined  with  a 
severe  pain  on  pressure  over  one  spinous  process,  possibly  with  some 
anterior  displacement  thereof,  and  moreover  if  there  is  also  a  local 
Inematoma  and  the  injury  has  been  direct  and  narrowly  circumscribed. 
The  early  diagnosis  of  fracture  of  the  arch  is  important  from  the 
point  of  view  of  treatment.  It  is  the  only  form  of  fracture  in  which, 
when  complicated  by  damage  to  the  cord,  early  operation  is  clearly 
indicated — the  elevation  or  removal  of  the  depressed  arch — and  in 
which  very  good  results  are  obtained. 

(3)  Compression-fracture. 
This  is  suggested  when  the  cord  symptoms  are  slight,  or  quite 
absent,  when  the  spinal  column  loses  its  hold,  either  incompletely  or 
not  at  all,  but  when — in  contrast  to  fracture  of  the  arch — there  is  very 
pronounced  pain  on  axial  pressure.  Caution  is  required  in  applying 
this  test.  The  injury  is  usually  in  the  nature  of  a  blow  in  the  long 
axis  of  the  body,  being  produced  by  a  fall  from  a  height  on  the  head 
or  the  feet,  or  on  the  buttocks.  The  bodies  of  the  vertebrae,  which 
are  chiefly  composed  of  spongy  bone,  yield  more  readily  to  these 
blows  than  the  arches  and  the  articular  processes,  which  are  mainly 
composed  of  compact  bone.  The  crushing  of  one  vertebral  body 
causes  the  spine  to  bend  forwards  in  an  angular  manner,  but  when 
several  vertebral  bodies  are  involved,  as  is  usually  the  case,  the  bend- 
ing is  more  like  a  kyphosis.  When  only  one  vertebra  is  compressed, 
the  curvature  may  be  limited  to  a  slight  prominence  of  the  spinous 
process  of  the  affected  vertebra,  and  a  hardly  perceptible  angular  kink 
in  the  spinal  column,  whereas  if  several  vertebrae  are  crushed  there  is 
always  a  round  curvature  (fig.  219).  Sometimes  one  has  to  search 
carefully  for  the  symptoms,  for  the  fracture  may  easily  be  overlooked 
in  the  absence  of  cord  symptoms,  especially  if  our  attention  is  diverted 
to  other  injuries  besides  those  of  the  spine,  or  if  the  patient  walks 
about  again  soon  after  the  accident. 

A  young  man  was  brought  into  the  hospital  with  a  compound 
fracture  of  the  skull  and  a  fracture  of  the  leg  after  falling  from  a 
scaffolding  on  to  his  head.  As  there  w^ere  no  suspicious  symptoms, 
the  spinal  column  was  not  specially  examined,  but  as  soon  as  the 
patient  left  his  bed  and  put  his  w^eight  on  his  spinal  column,  he  began 
to  complain  of  pains  in  his  back.  As  a  matter  of  fact  there  was  a 
slight  kink  at  the  level  of  the  fourth  dorsal  vertebra,  with  local  pain  on 
pressure,  which  must  have  been  due  to  compression-fracture. 

These  compression-fractures  are  most  frequently  found  in  the 
dorsal  and  lumbar  vertebrae.  When  situated  in  the  upper  dorsal 
vertebrae,  our  attention  is  often  directed  thereto  by  a  transverse  fracinre 
in  the  upper  portion  0/  the  steniitni. 

Slight    compression-fracture    in    the   lumbar   vertebrae    does    not 


506        SURGICAL    DISEASES    OF   THE   PELVIS   AND   SPIXAL   COLUMN 

usually  cause  any  visible  kink  or  protuberance.  The  change  of  form 
is  just  sufficient  to  straighten  out  the  normal  lordosis  of  the  lumbar 
spine. 

It  frequently  happens  that  vertebrje  which  have  been  damaged  by 
a  compression-fracture  undergo  secondary  absorption  of  bone,  and 
then  give  way  after  long  delay,  so  that  a  protuberance  appears  months 
after  the  accident — possibly  also  with  nervous  symptoms.  This  is 
known  as  Kiimmel's  disease,  and  is  also,  inappropriately,  termed 
traumatic  spondylitis. 

Axial  contusion  of  the  spinal  column  represents  the  slightest  degree 
of  damage  by  a  blow  in  its  long  axis,  the  intervertebral  discs  being 
especially  damaged.  We  may  diagnose  this  condition  when,  after 
such  an  injury,  there  is  pain  on  axial  pressure,  but  neither  any  change 
in  shape  nor  cord  lesion, 

(4)  Complete    Dislocation. 

Complete  dislocation  may  be  diagnosed  when  a  severe  or  complete 
cord  lesion  exists,  and  when  the  spinal  column  has  completely  lost  its 
supporting  power.  The  latter  symptom  is  not  always  present  in  com- 
plete dislocation  in  the  cervical  spine,  because  the  ligaments  may 
retain  some  supporting  power.  The  cord  lesion  is  much  less  severe  in 
these  cases  than  in  fracture-dislocation. 

A  very  powerful  trauma  is  required  to  cause  a  complete  displace- 
ment, and  it  must,  at  any  rate  partially,  be  of  the  character  of  an  over- 
bending.  The  diagnosis  must  be  based,  as  in  compression-fractures, 
on  the  presence  of  change  in  shape  of  the  spinal  column,  apart  from 
the  chief  symptoms  previously  mentioned.  But  the  nature  of  the 
injury  is  such  that  the  dislocation  may  rectify  itself  spontaneously  by 
appropriate  posture,  and  on  examination  it  may  not  be  possible  to 
discover  anything  beyond  a  spinous  process  which  is  painful  on 
pressure  and  is  depressed.  The  absence  of  any  striking  change  in 
form  does  not,  therefore,  exclude  a  complete  displacement  as  long  as 
indirect  symptoms  thereof  exist.  In  the  cases  wherein  the  change  in 
shape  persists,  we  find  an  increased  interval  between  two  spinous  pro- 
cesses. The  spine,  which  limits  the  gap  above,  is  depressed  forwards, 
in  consequence  of  the  displacement  of  the  vertebral  body,  with  which 
it  is  connected.  If  two  vertebrae  are  broken,  this  gap  is  found  between 
the  spines  of  these  two  vertebrae,  and  here  also  the  lower  spine  is  the 
more  prominent. 

An  exception  to  this  condition  occurs  in  the  rare  cases  when  the 
upper  vertebra  is  displaced  backwards  instead  of  forwards  (fig.  220). 

It  would  be  too  much  to  expect  any  further  details  in  diagnosis, 
and  to  decide  between  the  various  forms  of  complete  displacement,  in 
the  living  patient.  Besides,  it  is  quite  impossible  to  distinguish  oblique 
fracture-dislocations  from  dislocation-compression-fractures.     Indeed, 


SURGERY    OF    XOX-TRAUMATIC    DISEASES    OF   THE    SPINAL    CORD     507 

the  matter  has  no  practical  significance.  It  is  more  important  to 
be  able  to  distinguish  between  complete  dislocation  and  dislocation- 
fracture  in  the  cervical  spine,  because  the  former  is  capable  of  being 
correctly  reduced,  and  the  reduction  should  be  carried  out.  Complete 
dislocation  without  interlocking  of  the  articular  processes,  is  in  no  way 
distinguishable  from  dislocation-fracture,  because  in  the  latter  case 
also,  the  kinking  and  displacement  may  be  rectified  by  appropriate 
posture  (spontaneous  reduction).  It  is  quite  different,  however,  if 
complete  dislocation  is  combined  with  interlocking.  Whether  the 
head  is  bent  forwards  or  backwards  it  is  always  anteriorly  displaced  in 
relation  to  the  back,  and  there  is  no  tendency  for  it  to  return  to  its 
normal  position,  either  spontaneously  or  by  appropriate  posture.  This 
immovability  and  the  freedom  of  the  cord  should  always  suggest  a 
complete  dislocation  rather  than  a  dislocation-fracture,  and  we 
should  therefore  attempt  reduction.  A  skiagram  furnishes  conclusive 
evidence. 

Complete  dislocations,  pure  and  simple,  have  been  observed  in  the 
upper  dorsal  vertebrae,  but  they  resemble  dislocation-fractures  in  every 
respect,  and  it  is  quite  impossible  to  effect  any  reduction,  as  in  the 
case  of  dislocations  in  the  neck. 


CHAPTER   LXXVII. 

THE  SURGERY  OF  NON-TRAUMATIC  DISEASES  OF 
THE  SPINAL  CORD. 

The  recently  qualified  practitioner,  during  the  first  few  years  of 
practice,  usually  endeavours  to  classify  the  spinal  cord  diseases  which 
he  sees  under  one  of  the  schemes  he  learnt  as  a  student.  But  as 
their  memory  begins  to  fade  and  the  more  he  realizes  his  thera- 
peutic helplessness  the  simpler  become  his  diagnoses,  and  he  finally 
limits  himself  to  such  groups  as  tabes,  syphiHs,  paralysis  due  to 
spinal  caries,  infantile  paralysis,  and  "  obscure  diseases  of  the  spinal 
cord."  The  patient  suffers  no  great  harm  from  this  process  of 
simplification,  unless  his  case  happens  to  be  one  which  surgery  can 
cure,  or,  at  any  rate,  relieve.  This  applies  especially  to  tumours 
within  the  spinal  canal. 

Not  all  the  tumours  which  damage  the  spinal  cord  possess  equal 
interest  for  us.      If  an   obstinate  sciatica    or   an   intercostal   neuralgia 

33 


508         SURGICAL    DISEASES    OF   THE    PELVIS   AND    SPINAL    COLUMN 

comes  on  a  few  years  after  an  apparently  successful  operation  of 
cancer  of  the  breast,  it  is  easy  to  diagnose  a  secondary  growth  in  a 
vertebra ;  but,  unfortunately,  the  therapeutic  interest  is  ////.  If  a 
period  of  unexplained  neuralgia  is  followed  by  the  appearance  of 
a  tumour  on  the  surface  of  the  spinal  column,  and  if  the  spine 
kinks  simultaneously  with  the  sudden  onset  of  a  paraplegia,  there 
is  no  difficulty  in  diagnosing  a  primary  malignant  growth,  but  the 
therapeutic  significance  is  no  greater  than  in  the  case  of  a  secondary 
growth.  But,  in  addition  to  these  very  frequent  incidents,  tumours 
which  are  accessible  to  operative  treatment  occasionally  occur. 
Such  are  the  innocent  tumours  of  the  spinal  colmnii,  which  grow 
into  the  spinal  canal,  especially  osteornata,  fibromata,  and  choiidroinnfa 
and  hydatid  cysts,  and  also  new  groivths  and  in/iaiiinintorv granulation 
tnuionrs  of  the  spinal  cord  and  its  coverings. 

Root  symptoms,  most  of  a  sensory  character,  appear  first  as  a  rule ; 
i.e.,  localized  unilateral  neuralgias,  hyperaisthesia,  and,  finally,  anaes- 
thesia or,  at  any  rate,  hypo-aesthesia.  Motor  symptoms  very  rarely 
appear  first.  It  is  only  in  cases  of  tumour  of  the  cauda  equina  that 
the  root  symptoms  are  from  the  first  symmetrical  and  both  sensory 
and  motor  in  character. 

It  is  obvious  that  these  root  symptoms  do  not  exist,  or  at  least 
are  not  pronounced,  if  the  position  of  the  tumour  does  not  encroach 
upon  the  roots. 

Pressure  upon  the  spinal  cord  itself  begins  after  a  certain  time, 
varying  with  the  growth  of  the  tumour.  The  result  of  this  pressure 
is  more  or  less  loss  of  the  conducting  power  of  the  cord.  If  the 
tumour  has  a  lateral  situation  the  symptoms  are  essentially  those  of 
Brown-Sequard's  paralysis. 

Otherwise,  the  only  difficulty  in  determining  the  exact  relation 
of  the  tumour  to  the  spinal  cord  or  the  extent  to  which  it  has  pene- 
trated, is  due  to  the  fact  that  not  only  must  one  take  into  considera- 
tion the  anatomical  position  of  the  growth  but  also  the  susceptibility 
of  the  individual  nerve-tracts  to  pressure. 

The  following  questions  present  themselves  as  the  suspicion  of 
a  spinal  cord  tumour  arises  : — • 

(1)   Is  a  Tumour  Actually  Present? 

(a)  We  may  begin  with  the  stage  of  root  symptoms.  One  should 
think  first  of  tabes  in  the  differential  diagnosis  from  the  common 
spinal  cord  diseases  ;  but  this  condition  is  easily  recognized  by  its 
characteristic  symptoms,  especially  by  the  loss  of  the  knee-jerks. 
In  tumour  of  the  cord  these  are  increased.  Then  it  is  important 
to  decide  whether  the  symptoms  may  not  be  due  to  an  early  spinal 
caries  or  a  rare  hypertrophic  pachymeningitis  ;    but  the  symptoms 


SURGERY    OF   NON-TRAUMATIC    DISEASES    OF   THE    SPINAL    CORD      509 

are  usually  bilateral  in  these  conditions,  whereas,  in  cases  of  tumour, 
they  are  always  unilateral  at  first.  They  are  also  much  less  severe  in 
pachymeningitis  than  in  tumour.  It  is  more  difficult  to  exclude  a 
commencing  spinal  caries ;  indeed,  it  is  quite  impossible  to  make  a 
differentiation  as  long  as  the  symptoms  are  unilateral  and  no  change 
in  the  spine  can  be  detected  either  clinically  or  by  X-rays,  and  the 
patient  himself  is  not  tubercular  nor  possesses  hereditary  disposition 
thereto.  The  greater  frequency  of  herpes  zoster  in  cases  of  tumour 
furnishes  only  a  very  indefinite  indication,  and  nothing  but  the  con- 
tinued progress  of  the  case  can  elucidate  it.  In  spinal  caries  the 
root  symptoms  either  become  bilateral  in  the  course  of  a  few  months 
or  the  cord  symptoms  subside,  but  in  cases  of  innocent  tumour  the 
root  symptoms  may  remain  unilateral  for  years  without  any  other 
essential  changes  occurring. 

The  appearance  of  spinal  column  symptoms,  viz.,  pain  on  pres- 
sure, prominence  of  a  spinous  process  and  pain  on  axial  pressure, 
disposes  of  the  posssibility  of  spinal  cord  disease  and  pachymeningitis, 
as  well  as  of  tumour  of  the  spinal  canal.  The  diagnosis  must  then 
lie  between  spinal  caries  and  sarcoma  of  the  spinal  column  ;  but 
the  differentiation  is  sometimes  impossible.  The  fact  of  the  much 
greater  frequency  of  spinal  caries,  however,  justifies  the  practitioner 
in  diagnosing  that  condition.  If  the  case  is  not  eventually  cleared 
up  by  the  appearance  of  a  burrowing  abscess  on  one  side  or  the 
other,  or  by  metastatic  growths,  then  we  may  follow  Berard  in  decid- 
ing upon  the  possibility  of  a  tumour  if  confinement  to  bed  and  weight 
extension  produce  no  improvement.  A  skiagram  should  also  be 
taken. 

{h)  If  the  patient  has  paraplegia  without  any  deformity  in  the 
spinal  column  we  should  not,  even  then,  entirely  exclude  spinal  caries, 
although  this  would  be  a  very  rare  event.  The  case  is  more  likely  to 
be  chronic  myelitis,  or  multiple  sclerosis,  and  if  the  lesion  is  in  the 
cervical  cord,  hypertrophic  pachymeningitis.  If  a  neuralgic  stage 
preceded  the  paraplegia,  or  if  radiating  pains  persist,  we  may  exclude 
myelitis  and  multiple  sclerosis.  If  the  paraplegia  was  not  preceded 
by  pain,  the  diagnosis  may  be  in  doubt,  or  exploratory  operation  may 
be  indicated,  for  cases  of  spinal  cord  tumour  occur  wherein  sensorv 
root  symptoms  are  completely  absent. 

(c)  If  root  and  cord  syniptonis  have  occnrred  siinnltaneonslv  iviili 
deformity  in  the  spinal  column  the  diagnosis  lies  exclusively  between 
spinal  caries  and  malignant  growth.  If  a  burrowing  abscess  be 
present,  it  decides  the  matter,  but  sometimes  a  hydatid  cyst  which 
has  reached  the  surface  has  been  mistaken  for  such  an  abscess.  In 
the  absence  of  all  objective  indications,  we  must  rely  upon  the 
history,  and  if  the  symptoms  have  existed  for  years  we  must  attribute 


5IO         SURGICAL    DISEASES    OE   THE    PELVIS    AND    SPINAL    COLUMN 

them  to  spinal  caries  ;  if  their  course  has  been  rapid  and  does  not 
extend  beyond  months,  they  must  be  attributed  to  a  sarcoma.  Very 
vascular  sarcomata  are  sometimes  recognizable  by  loud  murmurs. 

(2)  What  is  the  Nature  of  the  Tumour? 

The  remarks  already  made  in  connection  with  tumours  of  the 
brain  apply  also  to  solid  tuberculomata  and  gummata  of  the  cord. 
The  history  should  guide  us,  but  not  control  us. 

Solitary  tubercles  may  exist  in  the  spinal  cord,  exhibiting  all  the 
symptoms  of  tumour.  They  may  be  shelled  out  like  tumours — an 
operation  which  has  been  attended  by  good  results. 

In  a  neighbourhood  where  the  echinococcus  is  endemic,  we 
should  think  of  the  possibility  of  hydatids,  and  our  diagnosis  would 
be  confirmed  if  the  patient  presented  any  other  localization  of  this 
disease.  Symptoms  which  have  persisted  for  years,  without  causing 
any  appreciable  change  in  the  spinal  column,  suggest  a  more  or  less 
innocent  tumour  of  the  spinal  canal,  especially  of  the  spinal 
meninges.  Schlesinger  holds  that  a  tumour  which  has  persisted  for 
more  than  three  years  is  generally  intradural  and  solitary,  and  therefore 
appropriate  for  operation.  The  more  localized  the  symptoms,  the 
more  hopeful  is  the  prognosis.  This  is  of  course  very  unfavourable 
in  the  case  of  the  more  widespread  symptoms  caused  by  sarcoma  of 
the  spinal  cord  itself. 

Operation  has  often  revealed,  instead  of  the  expected  tumour, 
localized  encapsuled  collections  of  serous  fluid  which  might  probably 
have  been  removed  by  simple  puncture  if  the  diagnosis  had  been 
possible  (Krause,  Oppenheim,  Nonne,  &c.). 

(3)  At  Which  Level  is  the  Tumour  Situated? 

The  accurate  diagnosis  of  the  level  is  an  indispensable  precedent 
of  operation.  Reference  should  be  made  to  the  remarks  in  con- 
nection with  spinal  cord  injuries,  and  it  is  only  necessary  to  add 
here  that  in  practice  the  level  which  is  diagnosed  is  usually  too  low. 
One  should  always  fix  upon  the  highest  possible  root  which  may  be 
involved  ;  but  this  may  often  be  too  low,  and  it  will  be  necessary  to 
search  higher  up  at  the  operation. 


INFLAMMATORY    DISEASES    OF   THE    SPIXAL   COLUMN  5 II 

CHAPTER  LXXVIII. 

INFLAMMATORY  DISEASES  OF  THE  SPINAL 

COLUMN. 

.J.— TUBERCULAR  CARIES. 

Tubercular  caries  is  so  much  more  frequent  than  any  other  form 
of  inflammatory  disease  of  the  spine  that,  as  far  as  the  practitioner  is 
concerned,  it  may  be  considered  as  the  only  important  one.  Diffi- 
cuhy  in  diagnosis  only  exists  before  the  appearance  of  the  charac- 
teristic symptom — sinking  in  of  the  diseased  vertebra  and  the 
resulting  deformity  of  the  spine,  the  so-called  Pott's  curvature. 

For  purposes  of  diagnosis  the  disease  is  divided  into  several 
classes  : — 

(I)  TUBERCULAR  CARIES  WITHOUT  DEFINITE  CURVA- 
TURE, AND  WITHOUT  A   BURROWING  ABSCESS. 

This  occurs  more  frequently  in  adults  than  in  children,  because 
the  diseased  vertebra  soon  softens  in  children,  and  the  curvature 
develops  early  in  a  pronounced  form.  Nevertheless,  a  careful  mother 
often  seeks  advice  before  the  disease  has  reached  the  stage  of 
deformity.  The  history  and  the  method  of  examination  varies  with 
the  age  of  the  patient. 

{a)  If  an  infant  is  brought  with  the  complaint  that  its  entire 
behaviour  has  changed,  that  it  is  in  marked  distress,  that  it  has 
become  helpless,  that  it  avoids  any  rapid  movement  of  the  body, 
that  it  cries  even  if  lilted  out  of  bed,  although  the  mother  is  sure  of 
not  having  hurt  it,  we  should  at  once  think  of  spinal  disease.  There 
is  probably  nothing  to  be  seen  on  the  back.  i\t  most,  there  may  be  a 
httle  rigidity,  combined,  perhaps,  with  some  scarcely  perceptible 
diffuse  kyphosis,  or  at  least  with  loss  of  the  normal  lumbar  lordosis. 
A  similar  kyphosis  is  seen  in  rickets,  but  the  spine  remains  movable 
in  that  disease,  and  the  back  at  once  makes  a  concave  bend,  if  we 
swing  the  child,  with  its  abdomen  downwards,  by  its  four  extremities, 
as  remarked  by  Hoffa.  In  spinal  disease  the  vertebral  column 
remains  rigid,  even  in  this  posture,  owing  to  the  muscular  fixation. 

We  might  also  be  misled  by  Barlow's  disease  (scurvy-rickets)  due 
to  improper  feeding.  In  this  condition  the  child  is  also  helpless,  and 
cries  when  moved;  but  the  pain  is  situated  in  the  legs,  and  not  in  the 
back.  Swelling  and  bluish-red  discoloration  of  the  gums  in  the 
vicinity  of  the  erupted  teeth  indicate  the  nature  of  the  disease. 

(b)  If  the  child  already  walks,  we  will  be  struck  by  the  fact  that  it 
no  longer  plays  with  other  children,  and  that  it  has  difficulty  in  going 
up,  and  especially  down,  stairs. 


512         SURGICAL   DISEASES   OF   THE    PELVIS   AND   SPINAL   COLUMN 

On  the  other  hand,  children  are  sometimes  seen  with  definite 
curvature,  but  without  any  subjective  disturbances.  This  means 
that  the  acute  process  is  over,  that  cicatrization  and  consohdation, 
which  take  place  much  earlier  in  children  than  in  adults,  have  already 
occurred. 


Fig.  222. — Early  stage  of  spinal  caries. 


Fig.  223.  —  Same  case,  seen  in  proSle. 


On  examination,  we  are  struck  by  the  rigidity  with  which  the 
spine  is  held,  and  by  the  way  in  which  the  child  carefully  avoids  any 
movement  of  bending,  over-straining,  or  rotating  the  spine.  If  the 
child  is  told  to  look  round,  he  turns  the  whole  body.     If  he  has  to 


INPM.AMMATORY   DISEASES   OF   THE   SPINAL   COLUMN 


513 


Fig.  224. — Early  stage  of  caries  in  cervical  spine.     At  X, 
edge  of  vertebral  body  eaten    away.    (From  living  subject. ) 


get  np  from  the  floor, 
ne  behaves  Hke  a  child 
with  progressive  muscu- 
lar atrophy,  i.e.,  he  sup- 
ports the  hands  on  the 
knees.  If  we  palpate 
the  vertebral  column, 
pressing  on  each  spi- 
nous process  separately, 
we  shall  be  able  to  elicit 
pain  at  one  delinite 
spot.  This  also  occurs 
if  we  press  upon  the 
spinal  column  in  its 
long  axis,  obviously 
with  care.  If  on  re- 
peated examination  we 

are  able  to  elicit  this  double  form  of  sensitiveness  to  pressure,  we  are 
justified    in   assuming   that    caries    has  started — although    it    may  be 
difficult  to  make  the  par- 
ents understand  that  some       1 

bone  has  already  been 
eaten  away,  notwithstand- 
ing the  striking  mildness 
of  the  symptoms.  It  is 
necessary  forthwith  to 
explain  the  significance 
of  the  disease,  otherwise 
it  is  impossible  to  secure 
the  requisite  careful  treat- 
ment, and  the  patience 
which  is  demanded  for  it. 
(c)  The  previous  his- 
tory will  be  somewhat 
■  more  ample  in  the  case 
of  older  ehihlren  and 
adults.  We  are,  however, 
liable  to  be  misled  in 
these  cases  unless  we  have 
the  possibility  of  spinal 
caries  in  view.  Sometimes 
the  patient  localizes  his 
pains  to  the  umbilicus. 
More  frequently   we   are 


ZtlX' 


X 


XI 


XE 


ZI 


Fig.  225. — Bending  of  spine  due  to  caries.  Greater 
part  of  nth  and  12th  vertebral  bodies  destroyed.  {Post- 
mortem preparation.) 


5H 


SURGICAL    DISEASES    OF   THE    PELVIS    AND    SPINAL    COLUMN 


consulted  for  sciatica,  indefinite,  abdominal,  or  lumbar  pains,  inter- 
costal neuralgia,  "rheumatic"  pains  in  the  arms  or  back  of  the  head. 
As  long  as  these  pains  are  unilateral,  the  diagnosis  is  often  very 
difficult.  But  they  almost  always  become  bilateral  after  a  few 
months,  thus  pointing  definitely  to  disease  of  the  spinal  column. 
As  previously  stated,  pain  in  the  back  on  going  down  stairs,  or 
knocking  up  against  a  stone  on  a  level  road,  is  quite  pathognomonic. 
An  elderlv,  apparently  vigorous,  man  became  paraplegic  without 
any  apparent   cause.     On   examination,  the  legs   were   found    to    be 


r 


^.-. 


•V? 


Fig.  225. — Caries  of  cervical  spine  {5th  and  6th 
vertebrae).  Head  displaced  somewhat  forwards. 
Neck   abnormally  wide  in  profile. 


Fig.  227.— Abscess  of  neck  due  to  caries. 


paralysed,  and  the  bladder  distended  to  the  umbilicus.  The  shape 
of  the  spinal  column  showed  nothing  special,  and  the  excellence  of 
the  general  condition  did  not  suggest  any  tubercular  disease.  The 
key  to  the  condition  was  found  in  the  patient's  statement  that  he  had 
felt  for  some  weeks  increasing  pain  in  the  back  when  walking  about, 
when  bending  his  spine,  and  especially  when  going  downstairs.  In 
such  a  case  the  question  of  a  primary  or  a  secondary  new  growth 
might  also  arise. 

The  occurrence  of  verv  severe  pain  in  the  lower  extremities,  on 
any  head  movement,  is  very  significant  of  commencing  tubercle  in 
the  cervical  spine. 


IXFLA^niATOKV    DISEASES    OF    THE    SPIXAL    COLUMX 


3^0 


The  patient  must  be  undressed  for  examniation,  and  must  stand 
with  his  knees  close  together,  and  be  directed  to  bend  his  back 
forwards  and  backwards.  If  tlie  movement  is  but  slow  and  imperfect, 
and  limited  to  the  hip  and  knee  joints,  it  must  excite  very  grave 
suspicion,  especially  if  the  attempt  to  bend  the  spine  backwards  is  a 
failure,  and  causes  the  patient  to  groan.  There  can  be  no  doubt 
about  the  diagnosis  if,  in  addition,  pain  on.  axial  pressure  is  present. 

This  latter  test  mu.->t  be  done  verv  carefullv,  especiallv  if  the  disease 
is  in  the  cervical  spine.  We  should  not  take  the  risk  of  making  a 
patient  paraplegic,  or  breaking  off  the  odontoid  process  of  the  axis, 
\n  order  to  establish  the  diagnosis. 

On  pressing  upon  each  separate  spinous  process,  the  detection  of 
the  diseased  vertebra  usuallv  becomes  very  easy.  Careful  palpation 
and  inspection  of  the  patient  in  profile  may  probably  reveal,  even  at 
this  stage,  some  slight  projection  bevond  the  adjoining  spinous  pro- 
cesses (fig.  223),  if  this  is  not  already  evident  from  behind  (fig.  222). 
In  caries  of  the  cervical  spine  there  will  also  be  some  rigidity,  and 
often  some  slight  displacement  of  the  head  forwards  (widening  of 
the  neck  m  profile)  before  any  definite  curvature  is  evident  (fig.  226). 

The  cases  wherein  these  primary  symptoms  of  pain  on  axial 
pressure  and  local  tenderness  are  absent  are  more  difficult  to 
diagnose. 

A  vigorous  young  girl,  aged  20,  the  picture  of  health,  began  to 
complain  of  lumbar  pains,  and  wandered  therewith  from  one  hospital 
to  another.  The  brother  was  tubercular.  Caries  was  thought  of, 
but  the  most  careful  examination  failed  to  substantiate  this  view. 
The  diagnosis  remained  in  suspense  until  a  burrowing  abscess  con- 
firmed the  suspicion.  Even  then  there  were  no  appreciable  symptoms 
in  the  spinal  column.  The  patient  died  from  amyloid  disease  two 
years  later.  Fig.  225  is  the  skiagram  of  the  preparation,  and  it  shows 
ver}^  clearh"  the  process  of  the  formation  of  the  curvature. 

The  skiagram  does  not  alwavs,  however,  show  anvthing  conclusive 
in  the  early  stage  of  cases  of  this  kind. 

(2)  SPINAL  CARIES  WITH   BURROWING  ABSCESS. 

In  every  case  of  spinal  caries  we  must  look  for  that  common 
accompaniment  of  all  tubercle  of  bone— a  cold  abscess — which  is 
termed  a  burrowing  abscess,  because  of  its  usual  course.  Its  im- 
portance for  diagnosis  and  treatment  is  evident  from  the  fact  that  it 
is  present  in  at  least  one-fourth  of  the  cases — according  to  other 
statistics,  one  half. 

There  are  cases  wherein  a  burrowing  abscess  is  the  first,  and  for  a 
long  time  the  only  appreciable  sign  of  spinal  caries.  Before  we 
discuss  its  diagnosis,  we  will  briefly  refer  to  its  anatomical  relations,. 

In  caries  of  the  upper  cervical  spine  it  is  found  in  the  posterior 
pharyngeal  wall,  or,  more  frequently,  at  the  side  of  the  neck,  in  front 
of   or   behind   the  sterno-mastoid.     Exceptionallv   it  may    run   under 


5l6        SURGICAL    DISEASES    OF   THE    PELVIS    AXD    SPINAL    COLUMN 

the  clavicle  towards  the  axilla.  If  the  caries  affects  the  loiver  cervical 
spine,  and  the  abscess  originates  in  the  transverse  process  or  the 
vertebral  arch,  it  mav  also  run  under  the  muscles  of  the  back,  but  as 
a  rule  it  tracks  along  the  oesophagus,  penetrates  the  thorax,  and 
behaves  like  abscesses  which  are  derived  from  the  dorsal  vertebra;. 
The  latter  reach  the  surface  between  the  twelfth  rib  and  the  ilium, 
or  they  dive  down  deeply,  following  the  large  vessels  over  the  ileo- 
psoas  muscle  as  far  as  Poupart's  ligament,  and  eventually  burst 
somewhere  through  the  muscles  and  reach  the  surface. 

If,  in  lumbar  caries,  the  diseased  focus  is  in  the  body  of  the 
vertebra,  the  abscess  burrows  in  front  of  the  spine,  in  the  sheath 
of  the  psoa:^,  travelling  downwards  either  over  or  under  Poupart's 
ligament,  to  appear  in  the  inguinal  region  or  in  the  anterior  femoral 


Fig.  228. — Caries  of  4ih  lumbar  vertebra,  with 
bilnteral  inguinal  burrowing  abscess. 


Fig.  229. — Commencing  abscess  in  tubercle  of 
left  sacro-iliac  joint. 


triangle.  The  abscess  appeared  in  the  former  position  in  the  case 
illustrated  in  fig.  228.  Despite  the  two  burrowing  abscesses,  there 
was  neither  curvature  nor  definite  disturbance  of  function  at  first ; 
nothing  but  slight  tenderness  on  pressure  over  one  spinous  process. 
The  skiagram  showed  clearly  that  the  fourth  lumbar  vertebra  was 
affected. 

More  rarely  the  abscesses  follow  the  hypogastric  artery  and  the 
sciatic  nerve,  traverse  the  great  sciatic  foramen,  run  under  the  gluteal 
muscles,  and  sometimes  from  there  proceed  to  the  posterior  surface 
of  the  thigh. 

If  the  focus  of  disease  is  situated  in  the  lateral  portions  or  in  ilie 
vertebral  arcJi,  the  abscess  appears  on  the  back. 


INFLAMMATORY   DISEASES   OF   THE   SPINAL   COLUMN  517 

The  same  applies  to  foci  of  disease  which  are  situated  posteriorly 
in  cases  of  tuberculosis  of  the  sacrum,  or  of  the  sacro-iliac  Joint.  But 
if  the  disease  is  situated  on  the  anterior  surface  of  this  joint,  the 
pus  gains  access  to  the  sheath  of  the  iliacus  muscle,  fills  the  side 
of  the  pelvis,  and  may  burrow  thence  under  Poupart's  ligament  into 
the  thigh  (fig.  230,  so-called  iliac  abscess).  It  is  then  situated  either 
at  the  side  of,  or  beneath  the  sartorius.  If  the  focus  of  the  disease 
is  more  deeply  situated,  the  abscess  burrows  towards  the  perinaeum 
and  makes  its  appearance  there  as  a  peri-rectal  abscess. 

If  we  have  already  ascertained  the  correct  diagnosis  by  means 
of  signs  in  the  vertebral  column,  there  is  no  difficulty  in  under- 
standing the  significance  of  a  burrowing  abscess.  But  if  this  is  the 
first  symptom  which  the  patient  notices,  and  for  which. he  consults 
the  doctor,  many  errors  of  diagnosis  are  possible,  as  already  mentioned 
in  detail,  unless  a  careful  examination  is  made. 

We  may  summarize  these  once  again  for  the  purpose  of  taking 
a  rapid  view  of  the  position. 

In  the  iicck  one  might  think  of  a  deep  lipoma,  a  deep  branchial- 
cleft  cyst,  or  of  an  oesophageal  diverticulum.  Burrowing  abscesses 
have  even  been  mistaken  for  goitres. 

In  the  tlionix  one  should  think  especially  of  lipoma,  cold  abscess 
originating  in  the  rib,  or  a  pleural  effusion  which  has  spontaneously 
broken  through. 

In  the  lumbar  region  one  should  think  of  lipoma,  lumbar  hernia, 
caries  of  the  ribs  or  pelvis,  and  also  of  the  possibility  of  a  tubercular 
perinephritis,  which  has  burst  through  posteriorly.  The  urine  must, 
therefore,  be  examined  in  every  case  of  lumbar  abscess. 

An  abscess  of  the  pelvic  fossa  may,  if  on  the  right,  be  mistaken 
for  an  ileo-ca?cal  tumour;  if  on  both  sides,  for  caries  of  the  pelvis 
or  chronic  pelvic  osteo-myelitis,  or  even  for  pelvic  tumours.  The 
correct  diagnosis  depends  upon  the  accurate  observation  of  the 
superior  connections  of  the  swelling.  Very  frequently  flexion  of  the 
hip-joint  is  produced,  and  thus  spinal  caries  may  be  mistaken  for  hip 
disease.  The  pelvic  cavity  must,  therefore,  be  examined  as  thoroughly 
in  what  is  apparently  hip  disease  as  in  spinal  caries. 

Abscesses  of  the  pelvic  fossa,  as  we  have  already  seen,  consist 
of  iliac  and  psoas  abscesses.  When  there  is  extensive  suppura- 
tion, it  is  not  possible  to  draw  a  sharp  distinction  between  the  two 
forms,  nor  is  it  important  to  do  so.  The  occurrence  of  clinically 
primary  suppuration  in  the  psoas  muscle  is  exceedingly  rare,  and 
then  it  is  generally  to  be  attributed  to  some  trauma.  This  condi- 
tion might  justify  the  popular  old  term  "psoas  abscess"  as  a  separate 
disease. 

Inguinal  abscesses  have  been  mistaken  for  inguinal  hernia  and 
hydrocele  of  the  canal,  especiallv  in  women.  But  these  abscesses  are 
situated  more  towards  the  side,  and  have  a  wide  connection  with  the 
pelvic  bone  by  broad  processes,  so  that  this  mistake  should  be 
avoided  ;  the  veiy  rare  bilocular  hydroceles  may,  however,  still  give 
rise  to  ditficultv. 


5i« 


SURGICAL    DISEASES    OF   THE    PELVIS    AND    SPIXAL   COLUMX 


Abscesses  of  tJie  fJiigJi  may  be  mistaken  for  femoral  herniae,  if 
situated  in  the  middle  line  immediately  under  Poupart's  ligament ; 
if  towards  the  side,  for  an  enlargement  of  the  sub-iliac  bursa.  If  the 
pus  can  be  displaced  at  all,  it  goes  back  gradually,  a  hernia  goes  back 
with  a  jerk.  If  it  is  not  displaceable — this  is  the  rule — its  consis- 
tence is  generally  elastic  or  fluctuating,  which,  of  course,  excludes  a 


r 


Fig.  230. — Burrowing  abscess  in  the  iliac  fossa  in  a  case  of  sacro-iliac  tuberculosis. 


Fig.  231. —  Caries  of  the  dorsal  spine  with  a  transversely  divided  burrowing  abscess  sac. 


hernia.  An  enlarged  bursa  is  i"ecognized  by  its  deep  situation  under 
the  iliacus,  whereas  an  abscess,  even  if  it  descends  Avithin  the  sheatli 
of  the  muscle,  always  has  a  tendency  to  reach  the  surface.  Manv 
burrowing  abscesses  are  distinguished  by  possessing  a  subdivided 
sac  (fig.  231).     If  the  femoral  abscess  is  situated  lower  down,  it  ma\- 


INFLAMMATORY    DISEASES    OF   THE    SPINAL   COLUMN  519 

be  mistaken  for  sarcoma  of  the  femur,  or  of  the  adductor  muscles. 
The  flexion  of  the  hip-joint  may  sometimes  suggest  hip  chsease. 

Unless  the  hip-joint  is  itself  secondarily  affected  with  tubercle,  a 
burrowing  abscess  due  to  spinal  caries  only  prevents  extension, 
whereas  in  true  hip  disease  abduction  and  rotation  are  especially 
limited. 

In  perineal  abscesses  the  diagnosis  has  to  be  made  from  dermoids 
and  the  various  forms  of  peri-proclitis.  The  most  likely  diagnosis  in 
the  rare  cases  of  gluteal  burrowing  abscesses  is  hip  disease,  which  can 
only  be  excluded  by  a  careful  investigation  of  the  spinal  column  and 
the  hip-joint. 

The  origin  of  doubtful  cases  of  suppurating  tistulae  is  best  ascer- 
tained by  means  of  a  skiagram,  after  they  have  been  injected.  The  most 
useful  preparation  for  this  purpose  is  one  composed  of  vaseline  with 
20  per  cent,  of  zircon  oxide,  a  modification  of  Beck's  methods,  as  bis- 
mutli  salts  are  not  quite  free  from  risk. 

(3)  SPINAL  CARIES  WITH  CURVATURE. 

Once  the  typical  curvature  is  developed,  a  glance  at  the  patient's 
back  suffices  for  the  diagnosis.  It  is  usually  very  easy  to  avoid  any 
confusion  with  spinal  deformities  due  to  other  causes.  As  the  kyphosis 
in  spinal  caries  depends  upon  the  destruction  of  one,  or  at  most  of  two 
or  three,  vertebrae,  it  appears  more  or  less  in  the  form  of  an  angular 
kink,  the  apex  of  which  is  formed  by  one  spinous  process.  All  other 
changes  in  the  shape  of  the  spinal  column,  except  those  which  result 
from  accidents,  are  not  merely  kinks  but  curves,  because  they  concern 
several  vertebrae.  There  should  never  be  any  confusion  with  scoliosis 
and  kypho-scoliosis,  because  lateral  curvature  is  so  predominant  in 
these,  but  is  only  very  exceptionally  present  in  tubercular  disease. 
Even  if  a  vertebra  is  diseased  asymmetrically,  as  occurs  occasionally, 
and  therefore  breaks  down  more  on  one  side  than  on  the  other,  there 
is  no  real  scoliosis,  but  always  an  essentially  anterior  kink,  a  gibbus. 
In  rachitic  bending  of  the  spine,  the  result  is  more  fiequently  pure  or 
nearly  pure  kyphosis,  and  the  deformity  consists  of  a  definite  curve 
and  not  of  kiiik.  If  a  child,  suspected  of  caries,  is  carefully  suspended, 
by  ail  its  limbs,  with  the  abdomen  downwards,  the  back  will  bend  in 
rickets,  but  not  in  caries. 

(4)  SPINAL  CARIES  WITH  CORD  SYMPTOMS. 

If  a  patient  with  spinal  caries  becomes  affected  with  spastic  para- 
plegia, it  obviously  indicates  compression  of  the  cord,  but  simple  loss 
of  power  of  gait  is  sometimes  ascribed  to  the  vertebral  disease,  although 
it  is  really  the  result  of  an  early  spastic  paraparesis.  We  may  even  go 
further  ;  any  definite  increase  in  the  tendon  reflexes,  in  tlie  parts  supplied 
from  below   the   lesion,  must   be  regarded  as   a   sign   of  commencing 


520         SURGICAL    DISEASES    OF   THE    PELVIS    AND    SPINAL   COLUMN 

pressure.  Sometimes  sv77//)/07/zs  of  pain  predominate  ;  occipital  neuralgia 
in  "  malum  sub-occipitale,"  neuralgic  pains  in  the  arms  in  caries  of 
the  lower  cervical  vertebrae,  crural  neuralgia  and  sciatica  when  the 
lumbar  spine  is  atfected — sometimes  also  in  cervical  caries.  These 
symptoms  point  to  compression  of  the  roots  and  should  prepare  us 
for  the  rapid  onset  of  cord  symptoms,  or  compel  us  to  try  to  avoid 
them  by  means  of  permanent  extension.  The  absence  of  dislocation 
of  a  vertebra  in  no  way  negatives  the  diagnosis  of  damage  to  the 
cord,  which  is  often  involved  in  an  actual  extension  of  the  disease  to 
the  membranes,  and  is  not  compressed  by  displacement  of  the  vertebra. 
In  such  cases  there  is,  of  course,  but  little  to  be  expected  from  extension 
treatment. 

In  a  case  wherein  all  four  extremities  were  completely  paralysed, 
I  found,  at  the  posf-niorfcm,  nothing  but  tubercular  pachymeningitis  of 
the  cervical  cord,  and  no  displacement  of  vertebrae  at  all. 

5.— NON-TUBERCULAR  INFLAMMATION  OF  THE  SPINAL 

COLUMN. 

We  have,  hitherto,  been  assuming  that  the  spinal  disease  is  of  a 
tubercular  nature,  which,  as  a  matter  of  fact,  is  true  for  the  majority 
of  cases.     But  there  are  various  exceptions  to  the  rule. 

Certain  changes  in  the  spine,  for  instance,  follow  injuries,  and 
the  significance  of  these  has  loomed  large  since  the  prevalence  of 
insurance  against  accidents. 

An  elderly  man  rolled  down  a  small  incline  in  his  garden.  He  felt 
some  pain  in  the  lower  portion  of  his  cervical  spine,  but  only  kept  his 
bed  for  a  short  time.  Later  on,  his  cervical  spine  began  to  bend 
forwards,  and  there  developed  a  curvature  which  was  something 
between  an  angular  kink  and  a  roundish  kyphosis.  There  was  no 
burrowdng  abscess,  no  pyrexia,  &c.,  and  the  vertebra  which  formed 
the  apex  of  the  curve  was  not  tender  on  pressure. 

Did  the  patient  suffer  from  tubercular  caries  of  a  traumatic  nature, 
brought  on  by  his  fall  ?  It  is  possible,  but  experience  shows  that  a 
similar  clinical  picture  may  develop  without  any  tubercular  change. 
The  comparatively  short  period,  during  which  pain  w^as  complamed 
of,  is  very  unlike  tubercle.  It  is  much  more  likely  that  the  patient 
sustained  a  compression-fracture  of  the  spine,  and  that  the  damaged 
vertebral  body  gradually  broke  up  and  sunk  in  ;  and  we  may  be  quite 
reassured  as  to  the  further  progress  of  the  case,  even  if  a  permanent 
protuberance  remains  on  the  back. 

The  diagnosis  may  be  very  difficult  in  cases  wherein  the  original 
trauma  was  slight,  and  the  development  of  the  curvature  very  slow, 
as  previously  mentioned  (Chapter  LXXVI).  The  cases  in  which  the 
symptoms  of  pain  persist  for  a  long  time  also  suggest  spinal  caries. 


INFLAMMATORY    DISEASES    OF    THE    SPINAL    COLUMN  52 1 

We  either  have  to  leave  the  diagnosis  in  doubt,  or  base  it  upon  the 
presence  or  the  absence  of  other  tubercular  manifestations,  unless 
a  skiagram  or  a  burrowing  abscess  decides  the  matter. 

A  kink  or  a  bend  is  not  always  the  most  prominent  result  of  an 
injury.  In  rare  cases,  rigidity  of  the  spinal  column  is  the  chief 
symptom,  which  may  be  associated  with  an  extensive  but  slight 
kyphosis  of  the  major  portion  of  the  spine.  Bechterew  has  described 
such  a  case,  in  which  bony  union  of  the  vertebral  bodies  was  found. 
The  accompanying  symptoms,  due  to  the  spinal  cord  and  the  nerve 
roots,  should  be  distinctive  of  this  condition. 

Another  variety  of  vertebral  disease  may  occasionally  be  confused 
with  caries,  namely  ankylosis  of  the  spine,  better  called  arthritis 
deformans  of  tJie  vertebral  Joints.  It  manifests  itself  by  gradual  stiffen- 
ing of  the  spine,  and  by  curvature.  The  disease  has  been  especially 
described  by  Striimpell,  and  by  Pierre  Marie. 

This  disease  is  characterized  by  the  simultaneous  ankylosing  or 
deforming  process  in  other  joints,  and  is  often  the  consequence  of 
some  infective  malady.  I  have  seen  it  in  association  with  chronic 
ankylosing  arthritis  of  the  elbow,  wrist,  one  knee  and  temporo- 
maxillary  joint. 

Confusion  with  spinal  caries  is  only  likely  to  occur  in  the  first 
stage  of  the  disease,  when  the  portion  of  vertebrae  originally  diseased 
— most  frequently  in  the  lumbar  spine — is  exceedingly  painful.  But 
the  subsequent  course  of  the  disease,  and  particularly  the  involvement 
of  various  other  joints,  makes  the  diagnosis  quite  clear. 

Gummatous  periostitis  in  tertiary  syphilis,  by  destroying  the 
affected  vertebrae,  may  produce  a  clinical  picture  very  similar  to 
spinal  caries.  The  diagnosis  must  be  based  on  the  history,  or  on 
Wassermann's  test,  and  on  the  result  of  specific  treatment. 

Finall}^,  one  should  mention  the  rare  occurrence  of  acute  osteo- 
myelitis of  the  spine,  and  that  metastatic  inflammation  of  the  spine  that 
has  been  observed  after  acute  infective  diseases,  such  as  pneumonia 
and  especially  typhoid  fever.  The  course  of  these  diseases  depends 
upon  the  virulence  of  the  organisms.  It  is  the  duty  of  the  practitioner 
to  detect  abscess  development  as  early  as  possible,  but  this  does  not, 
however,  occur  in  all  cases. 


522         SURGICAL    DISEASES    OF   THE    PELVIS    AND    SPINAL    COLUMN 

CHAPTER  LXXIX. 
SPINAL  CURVATURES. 

Orthop.-edics  has,  of  late,  become  so  much  of  a  speciaHty,  that 
not  only  the  general  practitioner  but  even  the  surgeon  gladly  leaves 
spinal  curvature  to  this  department.  Expedient  as  this  may  be  for 
therapeutics,  because  only  an  orthopaedic  institute  can  possess  all 
the  mechanical  apparatus  for  the  treatment  of  scoliosis,  it  is  not  so 
as  far  as  diagnosis  is  concerned.  To  detect  the  beginnings  of  scoliosis, 
nothing  is  required  beyond  an  observant  eye  and  a  plumb  line. 
Nevertheless  the  strictures  applied  by  Albert  years  ago,  in  regard  to 
overlooking  scoliosis,  are  equally  applicable  to-day.  Perhaps  lady 
doctors  would  have  the  advantage  in  the  diagnosis  of  this  condition, 
because  females  possess  a  keener  eye  for  deformity  than  males.  It 
is  for  this  reason  that  the  mother  first  detects  that  the  "  child  has  one 
shoulder  higher  than  another,"  or  that  "  the  back  or  hip  sticks  out." 

In  considering  the  causes  of  spinal  curvature,  we  must  recollect, 
as  Schulthesz  has  especially  pointed  out,  that  it  is  not  a  clinical  and 
etiological  entity,  but  is  in  most  cases  only  a  symptom.  When  the  statics 
of  the  body  are  disturbed  at  any  point,  the  spinal  column  provides 
for  the  restoration  of  the  equilibrium.  Shortening  of  one  leg  causes 
obliquity  of  the  pelvis,  and  a  corresponding  scoliosis  occurs  to  com- 
pensate for  this  disturbance  (figs.  232  and  233).  An  abnormal  in- 
clination of  the  pelvis,  due  to  flexion  of  the  hip,  is  compensated  for 
by  an  increased  lumbar  lordosis.  These  are  static  curvatures,  and 
are  recognized  by  their  disappearance  as  soon  as  the  pelvis  is  restored 
to  its  natural  posture  (figs.  232  and  233).  Temporary  curvatures  are 
often  due  to  some  painful  condition,  the  best  example  of  which  is 
sciatica  (fig.  234),  a  matter  to  which  we  shall  again  refer.  In  other 
cases  the  curvatures  are  due  to  disturbances  in  the  supporting  power 
of  the  muscles.  Thus  we  find  considerable  lumbar  lordosis  in  pro- 
gressive muscular  atrophy  (fig.  235)  ;  scoliosis  in  anterior  polio- 
myelitis, in  syringomyelia,  and  in  Friedreich's  disease  (fig.  236). 
Diseases  of  the  thoracic  organs  sometimes  are  at  fault,  as  in  the  case 
of  scoliosis  which  occurs  in  consequence  of  contraction  after  pleurisy, 
and  especially  after  empyema.  Heart  disease  with  enlargement,  by 
causing  asymmetry  of  the  thorax,  may  also  lead  to  curvature  of  the 
spine. 

We  should  only  look  in  the  spinal  column  itself  for  the  origin  of 
the  trouble,  if  we  have  excluded  all  these  causes.  Inflammatory 
diseases  play  their  part  among  these  spinal  changes.  Caries  leads 
mainly  to  kyphosis,  but  occasionally  produces  a  slight  lateral  curvature. 


SPINAL    CURVATURES 


523 


Arthritis  deformans  of  the  lumbar  spine  may  also  cause  lumbar 
kyphosis.  Injuries  may  be  responsible,  for  sometimes  kyphosis  is 
caused  bv  a  compression-fracture. 

P'inally  there  is  a  group  of  cases  in  which  the  change  in  form  is 
due  to  a  congenital  asyininetrical  dcforniitv  of  the  spine,  such  as  a  wedge- 


FiG.  232. — Lumbar  scoliosis  with  con- 
vexity to  the  left,  due  to  4  cm.  shortening 
of  left  leg. 


Fig.  233. — Same  case,  after  compen- 
sating for  the  shortening. 


shaped  outgrowth  of  a  vertebra,  with  a  supernumerary  rib  on  the 
broad  side,  or  fusion  of  two  vertebrae  on  one  side,  with  the  absence  of 
a  rib  on  that  side.  If  the  cervico-dorsal  portion  is  affected,  the 
deformity  manifests  itself  by  one  shoulder  " standing  out"  (fig.  237). 
This  congenital  prominence  of  a  shoulder  may  also  be  due  to  simple 

34 


524 


SURGICAL   DISEASES   OF   THE   PELVIS   AND   SPINAL   COLUMN 


muscular  anomaly,  or  to  a  clasp-like  bony  communication  between  the 
scapula  and  the  cervical  spine.  A  skiagram  is  always  required  to 
elucidate  these  conditions.  These  deformities  are  mainly  responsible 
for  the  so-called  "  numerical  variations  "  of  the  spinal  column,  i.e., 
they  interfere  with  the  ordinary  subdivision  of  vertebras  and  ribs  into 
the  separate  segments  (Dwight,  Bohm).  It  still  remains  to  indicate 
those  forms  of  slight  asymmetry  which  are  responsible  for  ordinary 
scoliosis. 


Fig.  234. — Scoliosis  due  to  sciatica. 


Fig.  235. — Progresfive  muscular 
atrophy  with  lordosis. 


The  further  consideration  of  this  subject  comprises  that  which  is 
usually  understood  by  the  term  "  airvatnres  of  the  spine." 

These  curvatures  are  (i)  symmetrical  or  antero-posterior,  (2) 
asvmmetrical  or  lateral. 


SPINAL    CURVATURES 


525 


(1)  ANTERO-POSTERIOR   CURVATURES. 

These  may  either  consist  of  an  abnormal  flatness,  the  bootmaker's 
type  of  spine,  or  of  an  increase  in  the  normal  curves,  or,  finally,  of 
really  abnormal  curvatures.  The  increase  of  the  normal  curve  in  the 
lumbar  region  constitutes  lordosis  and  in  the  back  kyphosis.  The 
mechanical  and  the  nerve  conditions  already  referred  to  are  the 
principal  causes,  but  rickets  and  osteomalacia  should  also  be  especially 
considered.     Then    there    is    the   so-called  "  round    back "   which    is 


Fig.  236. — Friedreich's  ataxia  with 
scoliosis. 


Fig.  237. — Congenital  cervico-dorsal  scoliosis 
with  convexity  to  the  right,  and  prominence  of  the 
shoulder,  due  to  a  symmetrical  outgrowth  of  spine 
and  ribs. 


iiereditary.  Such  abnormal  curvatures  as  lumbar  kyphosis  usually 
depend  upon  rickets  or  osteomalacia. 

The  diagnosis  of  these  antero-posterior  curvatures  is  easy.  It  only 
requires  some  slight  appreciation  of  form,  and  we  will  therefore  not 
dwell  on  it  any  longer. 

It  is  only  necessary  to  remark  that  one  must  examine  for  lateral 
curvatui-e  in  all  antero-posterior  curvatures.  Slight  scoliosis  with 
definite  torsion  is  often  concealed  behind  an  ordinary  round  back. 


526         SURGICAL   DISEASES   OF   THE    PELVIS   AND   SPINAL   COLUMN 

(2j   LATERAL  CURVATURES. 

Lateral  curvatures,  or  scoliosis,  involve  the  practitioner  in  great 
responsibility,  because  they  generally  bring  their  own  revenge  for 
delayed  treatment. 

The  patient  should  stand  for  examination,  completely  nude,  or  at 
least  undressed  as  far  as  below  the  hips  ;  the  two  feet  must  be  held  in 
the  same  posture,  the  arms  must  hang  down  loosely,  and  otherwise 
the  whole  attitude  must  be  as  unconstrained  as  possible.  Then  we 
look  at  him  from  the  back,  making  an  inspection  from  head  to  foot. 
We  note  whether  the  head  is  exactly  over  the  mid-point  of  the  feet, 
whether  it  is  held  obliquely  or  erect,  whether  the  shoulders  are  at  the 
same  level,  whether  the  scapulae  are  at  equal  distances  from  the  spine 
and  stand  out  equally  from  the  thorax.  Our  eyes  follow  the  line  of 
the  spinous  processes,  and  we  can  at  once  detect,  especially  in  thin 
subjects,  whether  the  furrow  between  it  and  the  transverse  processes 
is  equally  developed  on  both  sides,  or  whether  it  is  somewhat 
obliterated  on  one  side  and  deepened  on  the  other.  We  compare  the 
distance  of  the  arms  from  the  body,  in  other  words  the  two  triangles 
of  the  waist,  i.e.,  the  triangle  formed  by  the  arm  with  the  outline  of  the 
body,  and  also  the  shape  of  the  thorax,  the  position  and  shape  of 
the  hips,  the  level  of  the  gluteal  folds,  and,  finally,  the  shape  and 
posture  of  the  legs.  Then  the  patient  is  directed  to  walk  a  few  steps, 
in  order  to  see  whether  he  limps.  After  he  has  walked  round  the 
room,  we  tell  him  to  resume  his  former  position.  This  slight  inter- 
ruption in  the  examination  has  the  advantage  of  showing  us  whether 
the  posture  observed  at  first  is  really  the  normal  posture  of  the  patient. 
This  is  a  precaution  which  should  not  be  omitted  even  in  slight 
cases  of  scoliosis  which  can  easily  be  straightened  out,  and  especially 
not  in  cases  of  complete  scoliosis  (figs.  241  and  242).  We  next 
proceed  to  a  more  careful  examination  of  the  spinal  column.  We 
drop  a  plumb  line  (fig.  238)  from  the  seventh  cervical  spine,  and  note 
whether  it  falls  midway  between  the  buttocks,  and  lower  down 
between  the  feet.  We  thus  find  to  which  side  the  thorax  is  displaced, 
and  the  extent  of  the  displacement  in  relation  to  the  pelvis,  and  also 
the  distance  by  which  the  convexity  of  the  curvature  deviates  from  the 
plumb  line  (figs.  238  and  239).  We  then  feel  the  spine  and  mark  on 
the  skin  the  position  of  each  spinous  process  with  a  pencil.  This 
also  gives  the  opportunity  of  observing  whether  there  is  any  tender- 
ness on  pressure.  We  then  proceed  to  test  the  movement  of  the  spine, 
and  we  direct  the  patient  to  bend  his  back  forwards,  backwards,  and 
to  each  side,  with  his  knees  close  together.  This  examination,  in  the 
first  place,  will  reveal  any  caries  which  may  have  been  overlooked,  for 
the  movements  are  but  slightly  restricted  and  never  painful  in  scoliosis, 


SPINAL   CURVATURES 


527 


whereas  caries  may  always  be  recognized  by  painfulness  and  the- 
limitation  of  movement  by  pain  which  bears  no  relation  to  deformit3\ 
But  the  examination  of  the  back,  when  bending  forward,  teaches  us 
something  more.  On  inspecting  the  bent  back  from  the  nape  of  the 
neck  downwards^  we  may  be  struck  with  the  fact  that  one  side  of  the 


^^ 


Fig.  238. — Rachitic,  lumbar  scoliosis 
with  convexity  to  the  lefr,  and  dis- 
placement of  thorax  to  right,  i.e.,  to 
the  side  of  the  concavity  (through  over- 
compensation). 


Fig.  239.—  Dorsal  scoliosis  with 
convexity  to  left,  and  displacement 
of  thorax  to  left,  i.e.,  to  the  side  of 
the  convexity. 


thorax  is  higher  than  the  other,  that  is  to  say,  that  there  is  protuberance 
of  the  ribs  (figs.  243  and  245).  This  permits  us  to  estimate  the 
degree  of  torsion  of  the  vertebrje,  and  the  amount  of  the  deformity. 
We  can,  however,  usually  detect  the  protuberance  of  the  ribs  when 
the  patient  is  erect. 


Fig.  240. — Complete  scoliosis  with  convexity  to 
left,  displacement  of  thorax  to  right.  Right  waist 
triangle  enlarged.     Right  axillary  fold  shortened. 


Fig.  241. — Lumbar  scoliosis  with  convexity 
to  left,  of  very  slight  degree  ;  only  recognizable 
by  shape  of  waist  triangle. 


Fig.  242. — Lumbar  scoliosis  of  severe  de- 
gree with  convexity  to  the  left,  and  dorsal 
scoliosis  with  convexity  to  the  right.  Despite 
an  apparently  slight  curvature  of  the  spine,  the 
right  waist  triangle  is  deeply  indented. 


Fig.  243. — Same  case  as  fig.  242.  Pro- 
nounced protuberance  of  ribs  on  right  side, 
despite  an  apparently  slight  lateral  curvature. 


Fig.  244. — Severe  lumbo-dorsal  scoliosis,  with 
convexity  to  the  left  and  compensatory  dorsal 
set  1  Oils  with  convexity  to  the  right. 


Fig.  245. — Same  case  as  fig.  244.  Lower 
protuberance  of  ribs  to  the  left,  upper  pro- 
tuberance to  the  right. 


Fig.  246. — -Piimary  dorsal  scoliosis  with 
convexity  to  the  right.      Mild  case. 


Fig.  247. — Primary  dorsal  scoliosis,  with  con- 
vexity to  right.     Severe  case. 


530 


SURGICAL   DISEASES   OF   THE   PELVIS   AND   SPIXAL   COLUMX 


The  inexperienced  will,  however,  be  astonished  to  see  how  pro- 
nounced it  really  may  be,  when  the  back,  in  the  erect  posture,  appears 
to  be  fairly  normal  to  the  unpractised  eye.  Neither  should  we 
estimate  the  degree  of  change  exclusively  by  the  position  of  the 
spinous  processes,  because  they  always  remain  nearer  to  the  middle 
line  than  the  bodies  of  the  vertebras.  The  deformity  is  always  more 
noticable  on  the  skeleton  from  a  front  view  than  from  the  back,  and  the 
vertebral  spine  may  have  undergone  a  pronounced  lateral  deviation 
before  any  marked  displacement  of  the  spinous  processes  can  be 
detected. 


Fig.  248. — Primary  dorsal  scoliosis  wilh  convexity  to 
the  right.     Very  severe  case. 


Fig.  249. — Primary  dorsal  scoliosis  with  convexity 
to  the  left. 


The  examination  of  the  functions  of  the  spinal  column  indicates, 
fin.ally,  the  stage  of  the  deformity.  If  all  the  movements  are  carried 
out  symmetrically  to  the  same  extent,  and  if  the  deformity  vanishes 
with  the  movements,  or  if  it  is  only  noticed  occasionally,  for  instance 
when  the  muscles  of  the  back  are  tired,  the  case  is  in  an  early  stage, 
wherein  no  material  changes  in  the  spinal  column  have  yet  formed. 
Under  appropriate  treatment,  this  condition  may  be  cured  in  a  few 
weeks.  If,  however,  the  deformity  is  present  in  the  same  manner  at 
every  examination,  but  can  be  completely  straightened  out,  actively  by 


SPIXAL . CURVATURES 


531 


muscular  exertion  or  passively  by  suspension,  the  case  is  one  of 
iiiobile  scoliosis  (figs.  250  and  251).  Immediate  treatment  promises 
good  results  even  here.  We  must  not  be  content,  however,  witln 
prescribing  a  tonic  and  giving  general  directions  that  the  patient 
must  not  tire  himself.  We  must  either  take  the  treatment  in  hand 
ourselves,  energetically^and  complicated  apparatus  may  not  be 
required  in  this  stage — or  we  must  send  him  to  an  orthopaedic 
institute.  If  the  deformity  can  only  be  partially  straightened  out,  it 
is  in  a.  position  of  contracture;  if  it  cannot  be  straightened  out  at  all,  the 
case  is  one  of  fixed  scoliosis. 


Fig.  250. — Mobile  complete  scoliosis  with  con- 
vexity to  the  left.     Muscles  relaxed. 


Fig.  251. — Same  case,  with  the  muscles  tense. 


We  now  have  to  consider  tlie  Jonii  of  the  scoliosis.  If  the  whole 
spine  constitutes  one  carve,  we  speak  of  complete  scoliosis,  which  is 
usually  convex  to  the  left.  It  is  recognized  by  the  fact  that  the  waist 
triangle  on  the  convex  side  is  diminished  with  sharp  angles  above 
and  below,  whereas  on  the  concave  side  the  triangle  is  enlarged  and 
more  deeply  indented  (fig.  240).  In  early  cases  the  back  is  usually 
displaced  to  the  left  in  relation  to  the  pelvis. 

In  complete  scoliosis  the  protuberance  of  the  ribs  is  generally 
found  on  the  concave  side,  i.e.,  towards  the  right,  in  contrast  to  the 
condition  in  partial  scoliosis. 


532        SURGICAL   DISEASES   OF   THE    PELVIS   AND    SPINAL   COLUMN 

If  the  curvature  is  mainly  localized  in  the  lumbar  region,  we  speak 
of  hunbar  or  luinho-dorsal  scoliosis.  Here  also  the  convexity  is 
usually  to  the  left  (figs.  238,  240-245).  The  displacement  of  the 
back  in  relation  to  the  pelvis  is  more  pronounced  than  in  the  previous 
form,  the  waist  triangle  on  the  convex  side  is  also  diminished  or 
filled  out,  the  protuberance  of  the  ribs  is  on  the  convex,  i.e.,  the  left 
side.  In  slight  cases  the  shape  of  the  w^aist  triangle  is  the  only 
indication  of  the  curvature  (tig.  241).  This  form  has  a  great  tendency 
to  be  followed,  in  the  course  of  time,  by  a  compensatory  curvature  of 
the  dorsal  vertebrae  in  the  opposite  direction,  i.e.  towards  the  right, 
and,  of  course,  a  second  protuberance  of  the  ribs  develops  on  the  right 
side.  Fig.  245  illustrates  this  double  protuberance  of  ribs  in  a  severe 
case  of  dorsal  scoliosis  with  the  convexity  to  the  right. 

This  must  be  distinguished  from  primary  scoliosis  of  the  dorsal 
vertebrae,  wherein  the  curvature  has  its  convexity  to  the  right  (figs. 
246-248),  and  which  eventually  becomes  compensated  by  a  lumbar 
scoliosis  with  its  convexity  to  the  left.  The  whole  of  the  upper  part 
of  the  body  appears  to  be  displaced  to  the  right  in  relation  to  the 
pelvis.  The  right  arm  hangs  free  in  the  air,  whereas  the  left  is  closely 
applied  to  the  hip.  The  right  scapula  appears  to  project,  because 
it  is  pushed  forward  by  the  protuberance  of  the  ribs.  On  the  other 
hand,  the  left  scapula  is  reall}^  farther  away  from  the  body  than  the 
right  one,  because  it  lies  over  the  flattened  or  retracted  half  of  the 
thorax. 

Having  correctlv  ascertained  the  form  of  the  curvature,  our  next 
task  is  to  discover  its  cause.  There  is  no  difficulty  in  this  if  we  are 
told  by  the  mother  that  the  child  was  late  in  walking  and  in  talking, 
and  that  the  teeth  were  late  in  appearing,  and  if  we  also  find  evidences 
of  riclwts  still  persisting  in  the  skeleton.  We  may  also  obtain  some 
indications  from  the  form  of  the  rib  protuberance,  for  if  the  ribs  are 
bent  close  to  the  spine  this  points  strongly  to  rickets.  Some- 
times there  are  no  indications  of  definite  rickets,  but  other  abnor- 
malities of  the  skeleton,  such  as  flat-foot  or  knock-knee,  show  that  the 
cause  must  be  ascribed  to  late  rickets.  In  other  cases,  the 
■examination  of  the  brothers  and  sisters,  or  even  a  glance  at  the 
mother's  back,  may  show  that  there  is  a  hereditary  tendency,  which 
cannot  be  identified  with  rickets. 

Finally,  what  is  our  position  in  regard  to  school  scoliosis  f  There 
can  be  no  doubt  that  the  most  frequent  types  of  lateral  curvature 
are  commonest  among  school  children,  viz.,  lumbar  or  complete 
scoliosis  with  the  convexity  to  the  left  and  dorsal  scoliosis  with 
convexity  to  the  right.  On  the  other  hand,  we  often  see  these  types 
■develop  at  an  age  before  it  is  possible  that  the  posture  adopted  in 
writing  could  have  any  effect.      We  must,  therefore,  assume  that  the 


SPINAL    CURVATURES  533 

scoliosis  produced  in  school  develops  on  some  pre-existing  tendency 
thereto.  Not  only  do  the  cramped  posture  of  writing,  the  position 
of  the  copy-book,  and  the  shape  of  the  letters  contribute  towards  the 
development  of  the  curvature,  but  also  the  bad  habit  of  always 
carrying  the  school  books  home  under  the  same  arm.  Worse  than 
all  this,  however,  is  the  practice,  which  was  universally  prevalent  up 
to  a  few  years  ago,  of  making  children  sit  up  straight  for  hours  on 
forms  without  adequate  supports  for  the  back.  No  wonder  that  weak 
muscles  of  the  back  become  tired  and  the  spine  sinks  into  a  posture 
to  which  a  pathological  predisposition  inclines  it. 

This  predisposition  probably  depends  upon  an  exaggeration  of 
some  slight  asymmetry  of  the  spine,  normally  present.  But  this 
must  not  be  classed,  without  further  consideration,  with  the  condition 
previously  referred  to  as  ''numerical  variation,"  depending  upon  an 
essential  mal-development,  the  significance  of  which  is  not  quite 
clear. 


PART    VI. 

SURGICAL  DISEASES  OF  THE 
EXTREMITIES. 


CHAPTER  LXXX. 

FRACTURES  AND  DISLOCATIONS  OF  THE 
CLAVICLE. 

(i)  If  a  patient  is  unable  to  raise  his  arm  be3-c)nd  the  horizontal^ 
after  a  fall  on  the  shoulder  or  a  fall  on  the  arm  which  transmits  its 
force  to  the  shoulder,  if  he  inclines  his  head  towards  the  injured 
side  (fig.  252),  and  if  the  shoulder  appears  to  be  drawn  forwards  and 
inwards,  we  involuntarily  look  to  the  clavicle,  in  the  anticipation  of 
finding  a  fracture  in  its  outer  half  (fig.  252).  The  patient  suffers 
extreme  pain  when  the  fracture  is  manipulated.  But  this  striking 
picture  is  not  always  in  evidence.  In  children  especially,  the  fracture 
is  frequently  sub-periosteal — green-stick  fracture.  The  displacement 
is  limited  to  a  slight  angular  kink,  or  may  be  absent  entirely  ;  while 
the  power  of  movement  mav  suffer  no  definite  interference,  and  the 
arm  may  be  raised  vertically  without  any  hesitation.  The  careful 
observer  will,  however,  notice  that  the  child  takes  care  of  his  injured 
side  when  playing,  and  that  he  does  not  willingly  allow  himself  to  be 
led  by  the  affected  arm.  But  if  the  child  has  not  been  carefully 
observed,  as  is  so  often  the  case,  the  doctor  is  not  consulted  by  the 
parents  until  the  thickening,  due  to  callus,  has  made  its  appearance. 

(2)  Injuries  in  the  vicinity  of  the  sterno-clavicular  joint  are 
equally  easy  to  diagnose.  These  are,  with  few  exceptions,  disloca- 
tions, and  are  caused  by  dragging  on  the  shoulder-girdle  or  pressure 
thereon.  Inspection  and  comparison  with  the  opposite  side  indicate 
without  any  difficulty  whether  the  dislocation  is  forwards,  as  is  most 
usual,  or  upwards,  or  inwards  behind  the  sternum,  which  is  the 
rarest  variety.      Dislocation    of    the    sterno-clavicular   joint    is    often 


FRACTURES    AND    DISLOCATIONS    OF    THE    CLAVICLE 


535 


accompanied  by  other 
injuries,  especially 
fracture  of  several 
ribs,  when  there  has 
been  severe  compres- 
sion of  the  thorax. 
The  dislocation  may 
easily  be  overlooked 
in  such  cases,  be- 
cause the  fractured 
ribs  and  the  contusion 
of  the  lung,  which 
nearly  always  compli- 
cates these  severe  in- 
juries, concentrate  all 
attention. 

(3)  Injuries  in  the 
neighbourhood  of  the 
acromio-clavicular 
joint  are  more  inter- 
esting from  the  dia- 
gnostic point  of  view, 
loecause  they  are  more 
difficult  to  recognize. 
The  differential  dia- 
gnosis concerns  con- 
tusion, sprain,  and 
dislocation    of    the 


:j 


Fig.  252. — Fracture  of  the  right  clavicle. 

joint,  fracture  of  the  acromion,  and  of  the  extremity  of  the  clavicle. 
(a)   If  there  be  no  deformity,  and  pain  is  the  only  symptom,  we 

have    to    distinguish    between    contusion  and  sprain.     We    may  onlv 

assume  the  former  when  the 
joint  has  sustained  a  direct 
injury.  We  will  probably  find 
some  evidence  of  this  in 
bruising  which  has  super- 
vened, or  even  in  some  abra- 
sions. If  the  injury  was  in- 
direct, the  case  can  only  be 
one  of  sprain.  If  the  pain  is 
mainly  a  pressure  pain,  affect- 
ing the  whole  joint,  it  strongly 
suggests  contusion,  whereas, 
if    it    is    elicited     mainly     on 


Fig.  253. — Fractured  clavicle. 


536 


SURGICAL   DISEASES   GF   THE   EXTREMITIES 


movement— raising  the  arm  beyond  the  horizontal — and  if  the  pressure 

pain  is  limited  to  the  fold  of  the  joint,  it  suggests  sprain. 

{b)  A  slight  deformity,  consisting  of  a  little  step-like  ascent  from 

the  acromion  to  the  clav- 
icle, may  be  regarded  as 
a  sprain- — although  the 
condition  is  one  of 
loosening  of  the  liga- 
ments which  approxi- 
mates very  closely  to  a 
luxation.  There  is  no 
sharp  line  of  demarca- 
tion between  a  sprain 
and  a  subluxation.  On 
the  contrary,  fractures 
of  the  end  of  the  clav- 
icle or  acromin  may  be 
mistaken  for  sprains  or 
contusions  if  they  are 
periosteal,  and  there- 
fore produce  no  dislo- 
cation. If  there  is  also 
no  crepitus  on  move- 
ment,    nothing    but    a 

skiagram  can  demonstrate  the  presence  of  the  fracture. 

(c)   If,  however,  we  do  find  definite   deformity — and  this  usually 

consists  of  a  step-like  drop  of  the  shoulder  (fig.  254),  we  must  dis- 


FlG.  254. — Right  acromio-clavicular  dislocation. 


Fig.  255. — Skiagram  of  fig.  254  (taken 
from  behmd,  and  therefore,  apparently 
reversed). 


Fig.    256. —Detachment   of    distal 
end  of  clavicle. 


tinguish  between  (i)  fracture  of  the  outer  end  of  ilie  clavicle; 
(2)  acromio-clavicular  dislocatiou ;  and  (3)  fracture  of  the  acroniiou. 
Some  indication  is  afforded  by  the  position  of  the   maximum  pain 


FRACTURES    AND    DISLOCATIONS    ABOUT   THE    SHOULDER-JOINT       537 

on  pressure  and  of  the  displacement.  The  palpation  of  both  sides 
and  comparative  measurements  will  usually  clear  up  the  condition. 
In  doubtful  cases  the  irregular  shape  of  the  prominent  edge  and  the 
crepitus  permit  of  the  distinction  between  fracture  and  dislocation. 
The  differential  diagnosis  has  usually  to  be  made  between  dislocation 
and  fracture  at  the  end  of  the  clavicle.  In  addition  to  the  results  of 
palpation  and  measurement,  we  must  also  take  into  consideration  the 
visible  external  deformity.  A  very  striking  step-like  formation 
suggests  dislocation  rather  than  fracture.  The  severity  of  the  pain 
on  pressure  is  also  of  some  value,  because  it  is  more  pronounced  in 
fracture  than  in  dislocation.  The  skiagrams  are  easy  to  interpret,  and 
are  conclusive  (figs.  255  and  256). 

There  may  be  some  difficulty  in  interpretation  in  the  case  of 
children,  because  the  lateral  cartilaginous  portion  of  the  clavicle  is 
transparent.  A  fracture  of  the  cartilage  may  therefore  be  mistaken 
for  a  dislocation.  This  error  may  be  avoided  by  controlling  the 
skiagram  by  a  comparative  measurement  of  the  median  fragment. 

It  may  be  noted  finally  that  the  distal  end  of  the  clavicle  has 
occasionally  been  displaced  under  tlie  acromion,  and  even  under  the 
coracold  process.  These  rare  injuries  are  quite  recognizable  by  those 
who  are  skilled  in  palpation. 


CHAPTER    LXXXI. 


FRACTURES  AND  DISLOCATIONS  ABOUT  THE 
SHOULDER-JOINT. 

A  MERE  glance  and  an  examination  of  the  power  of  movement 
usually  suffice  to  make  a  diagnosis  in  the  case  of  a  patient  who  has 
fallen  upon  his  shoulder,  or  upon  his  arm,  the  latter  outstretched  to 
avert  the  fall.  If  we  employ  palpation  in  addition,  it  is  hardly  possible 
to  err,  unless  an  unusually  large  haematoma  renders  an  accurate  ex- 
amination impossible.  The  fact  that  so  many  errors  of  diagnosis  are 
actually  made  is  due  to  a  want  of  anatomical  consideration.  A  skia- 
gram, which  we  may  adopt  as  our  last  resource,  ought  only  to  confirm 
an  already  made  diagnosis  and  reveal  a  few  details,  but  should  never 
be  a  substitute  for  diagnostic  reflection. 

We  place  the  patient  before  us,  with  the  upper  part  of  his  body 
undressed,  and  direct  him  to  slowly  lift  both  arms  from  the  side.  If 
the  injured  arm  can  be  raised  perpendicularly,  the  shoulder-joint  is 


538 


SURGICAL   DISEASES   OF   THE   EXTREMITIES 


free,  and  there  is  certainly  no  serious  injury  of  the  shoulder  or  shoulder- 
girdle.  In  the  case  of  sub-periosteal  fracture  of  the  clavicle  in  children, 
free  movement  may  still  persist,  as  stated  in  the  previous  chapter. 

If  the  arm  on  the  injured  side  can  only  be  raised  above  the 
horizontal  line  in  a  hesitating  manner,  we  should  let  it  down  again 
gradually.  If  the  patient  lets  it  drop  from  the  horizontal  position  with 
a  sudden  grimace  of  pain,  we  may  be  almost  positive  that  the  collar- 
bone is  broken. 

If  the  arm  cannot  be  raised  at  all,  or  only  very  slightly,  or  if  the 


L 


Fig.  257. — Sub-coracoid   dislocation  of  humerus. 
Arm    abducted.     Axis  deviated   inwards.     Shoulder 
i^attened. 


Fig.  258. — Axillary  dislocalion  of  humerus.  A 
greatly  afjducted.  Axis  deviated  inwards  more  ii 
in  adjoining  case.  Shoulder  bulged  by  a  lai 
hiiemaloma. 


patient  supports  it  with  his  other  hand,  it  indicates  the  presence  of  a 
severe  injury — a  dislocation  or  fracture  about  the  shoulder-joint. 

In  dislocations  it  may  be  possible,  in  some  circumstances,  to  raise 
the  arm  as  far  as  the  horizontal  already  on  the  second  day,  with  a 
certain  amount  of  pain.  In  these  cases,  however,  it  will  be  observed 
that  the  movement  chiefly  takes  place  at  the  clavicular  joint. 

If  the  axis  of  the  humerus  is  deviated  inwards  so  that  the  continua- 
tion of  its  line  would  intersect  the  clavicle,  and  if  the  elbow  is  abducted 
from  the  side  of  the  body,  the  case  is  either  one  of  dislocation  or  of 
fracture.     If  the  curve  of   the  shoulder  is  flattened  (fig.  257)  it  is  a 


FRACTURES   AND    DISLOCATIONS   ABOUT   THE    SHOULDER- JOINT      539 

dislocation  ;  if  tlie  curve  is  retained,  it  is  a  fracture  (fig.  259).  This 
flattening  may,  however,  be  concealed  by  an  extravasation  of  blood 
(fig.  258) ;  but  if  dislocation  be  present  in  such  a  case,  pressure  with 
the  finger  below  the  acromion  would  show  that  the  glenoid  fossa  is 
empty,  in  comparison  with  the  other  side.  This  sensation  of  the 
emptiness  of  the  glenoid  fossa  is  so  unequivocal  that  if  it  is  not 
present,  we  may  positively  exclude  dislocation  in  any  doubtful  case. 
Unless  a  haematoma  had  attained  an  extraordinary  size,  it  could  not 
prevent  the  detection  of  the  gap  in  the  normal  position  of  the  head  of 
the  humerus.  Should  any  doubt  still  remain,  we  must  try  passive 
movements.  If  these  are  limited  in  certain  directions,  the  case  is 
certainly  one  of  dislocation  ;  if  they  are  normal  or  unusually  free, 
especially  in  the  direction  of  adduction  and  outward  rotation,  the  case 
is  one  of  fracture.  If  the  glenoid  cavity  is  empty,  but  crepitus  and 
preternatural  mobility  are  present,  the  rare  combination  of  fracture 
with  dislocation  exists. 

.4.— DISLOCATIONS. 

Having  diagnosed  a  dislocation,  we  have  next  to  decide  whether 
it  is  of  the  axillary  (sub-glen oid)  or  sub-coracoid  variety  ;  other  forms 
are  exceedingly  rare.  If  the  arm  is  greatly  abducted  from  the  side 
(fig.  258)  and  the  head  of  the  humerus  is  distinctly  felt  in  the  axilla, 
the  dislocation  is  axillary.  If  the  arm  is  less  greatly  abducted  and 
the  head  can  be  felt  and  seen  under  the  coracoid  process  (fig.  257), 
the  dislocation  is  sub-coracoid.  The  fact  that  the  head  of  the  bone 
can  be  seen  and  felt  in  Mohrenheim's  fossa  must  obviously  dispel  any 
doubt  about  the  presence  of  a  dislocation. 

We  purposely  do  not  lay  too  much  stress  upon  the  demonstration 
of  the  head  of  the  humerus  in  a  misplaced  position,  because  a  disloca- 
tion can,  and  should  be,  recognized  without  this  sign.  When  there 
has  been  much  extravasation  of  blood  with  infiltration  of  the  soft  parts, 
especially  in  an  axillary  dislocation,  it  is  often  impossible  to  make  this 
examination  without  an  anaesthetic,  and  many  a  dislocation  would  be 
overlooked  if  the  diagnosis  depended  upon  the  discovery  of  the  head 
of  the  humerus  in  an  abnormal  position. 

In  the  absence  of  any  considerable  extravasation  of  blood,  an 
indication  for  distinguishing  between  the  two  forms  of  dislocation 
may  be  obtained  from  the  amount  of  increase  in  the  circinnference  of  tJie 
shoulder-joint,  as  measured  through  the  axilla  and  over  the  acromion. 
If  the  increase  does  not  exceed  2  cm.,  the  dislocation  is  sub-coracoid, 
but  if  it  is  as  much  as  4  cm.  the  dislocation  is  axillary.  In  these 
cases,  however,  palpation  is  quite  easy,  and  if  there  is  much  extravasa- 
tion of  blood  the  sign  is  of  doubtful  value. 

One  who  is  able  to  recognize  these  two  important  varieties  of  disloca- 
tion of  the  shoulder  will  have  no  difficulty  in  detecting  the  rare  forms, 
wherein    the  head    of    the    humerus    is   in  front,    under    the    clavicle 

35       '  -  .  ■ 


540 


SURGICAL   DISEASES   OF   THE    EXTREMITIES 


(subclavicular  dislocation)  or  above  the  conicoid process  (supra-coracoid 
dislocation)  or  upwards  and  backwards  (sub-acromial  dislocation)  or 
backwards  and  downivards  (infra-spinous  dislocation).  We  must 
always  be  guided  by  the  three  above-mentioned  cardinal  signs,  (i) 
absence  of  the  head  of  the  humerus  from  its  normal  position,  (2) 
diminished  range  of  passive  movements,  and  (3)  the  presence  of  the 
head  in  an  abnormal  position,  a  sign  which  can,  as  a  rule,  be  easily 
demonstrated  in  the  forms  last  noted. 

5.— FRACTURES. 

If  the  head  of  the  hume- 
rus is  in  its  normal  position, 
and  passive  mobility  is  in- 
creased, or  remains  normal, 
while  active  movements  are 
quite  impossible,  and  the 
power  of  the  shoulder  is 
lost,  we  diagnose  a  fracture. 
This  may  be  confirmed  by 
feeling,  or  even  by  hearing 
crepitus  on  manipulation. 
This  symptom  is,  of  course, 
conclusive  when  present,  but 
its  absence  is  not  in  any 
sense  an  argument  agaiust 
fracture.  The  lower  frag- 
ment may  be  so  much  dis- 
placed that  it  no  longer  rubs 
up  against  the  upper  one,  or 
the  crepitus  may  fail  owing 
to  impaction  of  the  frag- 
ments, or  to  the  sub-perios- 
teal  position  of  the  fracture. 
In  cases  of  separation  of  the  epiphysis  in  young  people,  the  crepitus 
is  nothing  more  than  a  soft  grating  which  may  easily  be  overlooked. 
Disptaceuient  of  the  lower  fragineut  often  furnishes  further  confirma- 
tion of  the  diagnosis  of  fracture.  This  fragment  may  be  in  a  position 
of  abduction  or  of  adduction,  and  mav  also  be  completely  displaced, 
either  backwards  or  forwards.  We  have  already  studied  the  position 
of  abduction,  in  which  the  elbow  projects  away  from  the  side,  and  in 
which  the  axis  of  the  humerus  is  directed  towards  the  centre  of  the 
clavicle  (figs.  259  and  263),  because  of  its  similarity  with  the  usual 
posture  of  the  arm  in  dislocation.  The  position  of  adduction  is 
indistinguishable  from  the  normal  posture  of  the  arm,  and  therefore 
can    only   be   recognized    on   a   skiagram     (fig.    265).     The   forward 


Fig.  259.  —Fracture  through  the  tuberosities. 
Arm  abducted,  but  curve  of  shoulder  maintained 
(after  Kocher). 


FRACTURES   AND    DISLOCATIONS   ABOUT   THE   SHOULDER   JOIXT      54I 

displacement  of  the  shaft  of  the  hunTierus  is  of  greater  importance. 
This  displacement  is  recognized  by  the  fact  that  the  axis  of  the  arm, 
when  looked  at  from  the  side,  does  not  go  through  the  acromion,  but 
in  front  of  it.  If  there  is  any  doubt  about  this,  Ave  can  always  feel  that 
the  margin  of  the  lower  fragment  presses,  as  a  sharp  edge,  against  the 
anterior  surface  of  the  shoulder  circumference.  If  the  skin  itself  is 
impaled  by  the  lower  fragment,  so  that  a  dimple  forms,  there  can  be 
no  possible  doubt  about  the  existence  of  a  fracture.  The  same  applies 
jjiiitniis  nmtaiidis  to  the  rarer  forms,  in  which  the  humerus  is 
displaced  backwards. 

In    some   cases    nothing   abnormal    beyond  a   diffuse    swelhng   is 
visible  on  inspection,  and  neither  unnatural  mobilitv,  nor  crepitus,  can 


Fig.  260. — The  most  frequent  varieties  of  fracture  at  the  upper  end  of  the  humerus. 

T.  Fracture  of  the  anatomical  neck.  4.   Fracture  of  the  great  tuberosity.  5.  Y-Fracture. 

■a.   Fracture  through  the  tuberosities. 
3.   Fracture  below  the  tuberosities. 

be  detected,  owing  to  the  impaction  of  the  fragments.  Comparative 
measurements  of  the  length  of  the  humerus  from  the  acromion  to  the 
external  epicondvle  may  also  fail  to  give  any  positive  indication.  If 
it  were  not  that  the  persistent  loss  of  power  pointed  to  some  severe 
injury,  one  would  be  inclined  to  be  content  with  the  diagnosis  of 
contusion  of  the  shoulder.  In  such  cases  we  are  assisted  by  the 
presence  or  absence  of  "  fracture-pain."  We  press,  with  equal  force, 
the  tips  of  two  or  three  fingers  under  each  acromion.  A  circum- 
scribed severe  pain  resulting  from  this  pressure  points  to  fracture. 
Then  we  test  whether  axial  pressure  elicits  pain  ;  this  is  done  by 
pressing  the  elbow  upwards,  with  counter-pressure  over  the  shoulder. 
In  recent  cases,  the  presence  or  absence  of  pain  on  axial  pressure  is 
decisive,  for  or  against  fracture  respectively. 

If  there  is  no  displacement,  this  pain  on  axial  pressure  may  be 
v^ery  indefinite,  and  disappear  after  twenty-four  hours,  although  pain 
on  local  pressure  continues. 

It  is  never  justifiable  to  attempt  any  extensive  movements  under 


542 


SURGICAL   DISEASES   OF   THE   EXTREMITIES 


Fig.  261. —  Shattering  of  head 
of  humerus  (patient  was  run  over 
by  railway  carriage). 


Fig.  262. — Sub-coracoid  dislocation. 


Fig.  263. — Fracture  of  humetus,  through 
tuberosities,  in  position  of  abduction,  as  in 
dislocation  {cf,  fig.  262). 


Fig.   264. — Axillary  dislocation  with  detach- 
ment of  great  tuberosity. 


FRACTURES   AND    DISLOCATIONS   ABOUT   THE   SHOULDER-JOINT        543 


Fig.  265. — Fracture  of  humerus  through  tuber- 
osities, in  position  of  slight  abduction.  Also 
fracture  of  great  tuberosity,  indicating  Y-fracture. 


Fig.  266. — Fracture  of  humerus  through  tuber- 
osities in  position  of  adduction. 


Fig.  267.  —  Fracture  of  humerus, 
below  tuberosities  :  (a)  line  of  fracture  ; 
(b)  epiphyseal  line. 


Fig.  268. — Fractured  great  tuberosity  in  a  reduced 
sub-coracoid  dislocaiion. 


544  SURGICAL   DISEASES   OF   THE   EXTREMITIES 

an  anaesthetic  when  the  displacement  is  sUght  or  altogether  absent. 
Such  may  result  in  causing  a  very  undesirable  amount  of  displacement. 
The  diagnosis  of  fracture  can  be  based  upon  the  complete  loss  of 
power  and  the  pain  on  pressure.  The  variety  of  the  fracture  can  be 
ascertained  by  direct  palpation  and  by  noting  whether  the  great 
tuberosity  does  or  does  not  follow  the  movement  of  the  bone  on 
rotating  it. 

We  are  now  in  a  position  to  diagnose  the  precise  form  of  fracture,  if 
we  take  into  consideration  the  typical  lines  of  fracture  shown  in  fig.  260. 

It  is  only  possible  actually  to  feel  the  fracture  when  it  is  extra- 
capsular. Therefore  if  the  edge  of  a  fragment  is  felt  the  fracture  must 
either  be  through  the  tuberosities,  or  below  the  tuberosities.  The 
distance  of  the  edge  of  the  fragment  from  the  joint  indicates  which 
of  these  two  varieties  it  is.  If  the  edge  cannot  be  felt,  one  must  test 
whether  the  great  tuberosity  follows  the  movements  of  the  bone.  If 
the  great  tuberosity  moves  with  the  humerus  on  rotation,  the  fracture 
must  be  intracapsular — probably  a  fracture  of  the  anatomical  neck^ 
assuming  that  our  diagnosis  of  fracture  is  confirmed  by  crepitus.  But 
if  we  have  not  elicited  any  crepitus,  and  have  only  based  our  diagnosis 
on  the  presence  of  pain  on  axial  pressure,  there  may  be  an  impacted 
fracture  between  the  tuberosities  which  is  the  more  frequent  event. 

But  if  the  great  tuberosity  does  not  move  when  the  humerus  is 
rotated,  the  choice  lies  between  the  fracture  which  goes  through  the 
tuberosities,  and  the  fracture  which  runs  below  them.  Even  if  we  can- 
not feel  the  edge  of  a  fragment,  the  diagnosis  can  be  made  with  consid- 
erable accuracy  from  the  position  of  the  maximum  pain  on  pressure. 

Fracture  of  the  metaphysis  (between  the  epiphysis  and  the 
diaphysis)  caused  by  sudden  pressure,  for  instance,  by  a  blow  in  the 
direction  of  the  axis,  produces  the  least  symptoms.  We  will  describe 
this  form  of  fracture  in  connection  with  the  radius,  but  Iselin  has 
shown  that  this  variety  also  occurs  at  the  upper  part  of  the  diaphysis 
of  the  humerus.  The  diagnosis  can  only  be  made  from  the  local 
pain  on  pressure. 

If  the  great  tuberosity  is  detached  as  an  isolated  fragment,  it 
naturally  does  not  follow  the  humerus  on  rotation,  but  in  such  a  case 
there  is  no  pain  on  pulling  or  pressing  on  the  axis  of  the  limb.  This 
detachment  is  usually  a  complication  of  a  dislocated  shoulder  (figs, 
264  and  268),  and  the  signs  of  dislocation  are  therefore  predominant. 
The  complicating  fracture  can  only  be  recognized,  apart  from  a 
skiagram,  if  we  obtain  crepitus  or  are  able  to  feel  the  detached  great 
tuberosity  through  the  skin.  An  isolated  fracture  of  the  great 
tuberosity,  without  dislocation,  can  be  detected  by  the  circumscribed 
pain  on  pressure  if  the  displacement  is  slight.  If  the  displacement  is 
greater  and  the  patient  is  thin,  it  can  be  seen  that  the  shoulder  is 
flattened  out  and  broadened,  as  viewed  from  the  front.     There  will 


FRACTURES   AND   DISLOCATIONS   ABOUT   THE   SHOULDER-JOINT      545 


also  be  two  distinct  bulgings — the  one  behind  representing  the 
detached  tuberosity,  the  one  in  front  representing  the  somewhat 
anteriorly  displaced  head  of  the  humerus. 

As  the  external  rotators  (supra-  and  infra-spinatus  and  teres  minor) 
are  inserted  into  the  great  tuberosity,  active  external  rotation  becomes 
impossible,  and  the  arm  can,  at  most,  be  raised  as  high  as  the 
horizontal.  This  fracture  sometimes  occurs,  indirectly,  through 
muscular  contraction. 

It  is  only  in  thin  subjects,  and  when  there  has  been  little  extravasa- 
tion of  blood,  that  it  is  possible  to  suspect  clinically  a  Y-shaped 
fracture,  from  the  combination  of  symptoms  of  the  lines  of  fracture 

I  and  2,  or  2  and  4  (fig.  260).  The 
symptoms  of  separation  of  the 
epiphysis  resemble  those  of  frac- 
ture through  the  tuberosities. 


Fig.  269. — Fracture  through  the  tuber- 
osities. Taken  from  the  front.  No 
apparent  displacement. 


Fig.    270. — Same  case.      Taken    from    the 
side.     Displacement  evident. 


Special  mention  should  be  made  of  separation  of  fJie  epiplixsis,  in 
infants  during  delivery,  and  separation  of  the  epiphysis  in  infants  with 
congenital  syphilis,  owing  to  syphilitic  osteo-chondritis.  The  loss  of 
movement  in  the  arm  is  the  most  striking  symptom  in  these  children — 
so-called  "  pseudo-paralysis." 

If  the  shoulder  is  flattened  and  the  head  of  the  humerus  is 
approximated  to  the  thorax,  just  as  in  the  case  of  dislocation,  but  if,  at 
the  same  time,  there  are  increased  mobility,  crepitus  and  pain  on  axial 
pressure  as  in  a  fracture,  though  nothing  can  be  found  wrong  in  the 
humerus,  we  should  think  of  a  fracture  of  the  neck  of  the  scapula, 
more  especially  of  detachment  of  the  articular  process  and  coracoid 
process.  Confirmation  of  this  diagnosis  is  furnished  if  the  deformity 
is  corrected  by  displacing  the  humerus  to  the  side  and  pressing 
upwards,  and  by  the  return  of  the  deformity  immediately  the  pressure 
is  relaxed. 


46 


SURGICAL   DISEASES   OF   THE   EXTREMITIES 


Figs.  261  to  268  indicate  the  skiagraphic  appearances.  The 
importance  of  taking  a  lateral  view  (if  possible  with  the  arm 
abducted)  is  shown  by  comparing  Figs.  269  and  270. 

We  should  only  be  content  with  the  diagnosis  of  contusion  or 
sprain,  if  nothing  is  yielded  by  an  examination,  carried  out  as  here 
directed,  whether  the  injury  be  direct  or  indirect.  We  append  to  this 
chapter  a  summarized  table  which  will  facilitate  diagnosis  in  any 
given  case. 


ln^  „„-j  f^„„„  u    J       1     /Passive  movements  limited  in 

/(jlenoia  fossa  can  be  deeply  ^  ■         i-      ,•  /  jj 

.     - .    -^   1      certain     directions     (adduc- 
tion). 


pressed  into  ;  bead  of  hu- 
merus to  be  felt  in  an 
abnormal  position. 


Passive  movements  free. 


Curve   of  shoulder_/ 
flattened 


Shoulder  curve  re- 
tained 


Glenoid     fossa     cannot    be 


;  Head  of  humerus  shows  no- 
where circumscribed  pain  on 
pressure  (not  even  through 
the  axilla),  but  the  scapula 
is  painful  on  pressure  through 

-   -  ---      __         the  axilla.     Coracoid  process 

deeply  pressed  into  ;  head  /  follows  the  movements  of  the 
of  humerus  not  felt  in  an  \  arm.  The  whole  shoulder 
abnormal  position.  region  can  be  displaced  up- 

wards, but  immediately  sinks 
'      downwards  again. 

I  Circumscribed  pain  in  head  of 
\     humerus  on  pressure. 


Curve  over  shoulder  can  be 
deeply  pressed  in  ;  pas- 
sive movements  limited  ; 
head  of  humerus  can  be 
felt  in  abnormal  position 


Curve  over  shoulder  can- 
not be  pressed  in  ;  passive 
movements  free ;  head  of 
humerus   not   felt   in   ab- 

i     normal  position. 


No  pain  on  axial  pressure  ;  loss 
of  power  moderate  ;  no  local 
pain  in  bone  on  pressure ; 
pain  about  the  capsule. 

No  pain  on  axial  pressure. 
Severe  circumscribed  pain 
on  pressure  over  great  tu- 
berosity ;  active  outward 
rotation,  nil.  Rarely  tuber- 
osity can  be  felt  to  be 
movable. 

Pain  on  pulling  or  pressure  in 
long  axis ;  local  pain  on 
pressure,  especially  through 
axilla;  great  tuberosity  fol- 
lows rotation  ;  severe  loss  of 
power. 

Ditto,  but  the  pain  on  pressure 
through  axilla  is  felt  in 
scapula  and  not  in  head  of 
humerus  (see  also  above). 

Ditto,  but  pain  on  pressure  at 
level  of  tuberosity,  also  de- 
monstrable from  outer  side  ; 
loss  of  power  slight  or  dis- 
appears rapidly. 

Ditto,  but  great  tuberosity 
does  not  lollow  rotation  ; 
lower  fragment  often  dis- 
placed anteriorly  ;  anterior 
margin  can  be  telt  through 
deltoid  ;  loss  of  power  more 
than  in  lo,  but  in  children 
may  be  slight. 

Ditto,  but  local  pain  on  pres- 
sure below  the  tuberosities  ; 
site   of  fracture   clearly  felt 

\     from     the     axilla ;      loss     of 

\    power  very  great. 


(i)  Dislocation  of  hu- 
merus (usually  axil- 
lary or  sub-coracoid). 

(2)  Dislocation  with  frac- 
ture. 


(3)  Fracture   of   neck  of 
scapula. 


(4)  Fracture  of  humerus 

with  position  of  ab- 
duction. 

(5)  Dislocation      of     hu- 

merus  with    hsema- 
toma. 

(6)  Sprain  of  humerus, 


(7)  Fracture      of 
tuberosity. 


great 


(S)  Fracture    of  head  or 
anatomical  neck. 


(g)  Fracture   of    neck  of 
scapula. 


(10)  Impacted  fracture 
through  tuberosi- 
ties. 


(11)  Free  fracture  through 
tuberosities  (separa- 
tion of  epiphysis)  either 
without  displacement 
or  in  a  position  of  ad- 
duction, or  displace- 
ment anterior. 


(12)  Fracture  of  humerus 
below      tuberosities 

(surgical   neck). 


INFLAMMATORY   PROCESSES   ABOUT   THE   SHOULDER-JOINT         547 


CHAPTER    LXXXII. 

INFLAMMATORY    PROCESSES    ABOUT    THE 
SHOULDER-JOINT. 

Inflammation  about  the  shoulder  is  situated,  apart  from  rare 
exceptions,  in  the  biirscv,   the  joint,  or  in  the  bones. 

^.—DISTINCTION  BETWEEN  BURSAL  AND 
JOINT  DISEASE. 

The  snbscapnlar  bnrsa  and  the  bursa  bekveen  the  tuberosities  are 
only  dilatations  of  the  capsule  of  the  joint,  and  require  no  special 
attention,  because  they  are  never  diseased  independently.  The  sub- 
coracoid  bursa  is  too  small  to  be  of  any  importance.  The  bursa  under 
the  deltoid  is,  however,  of  importance  pathologically.  It  lies  between 
the  deltoid  muscle,  the  capsule  of  the  joint  and  the  humerus,  and 
is  often  subdivided  into  two  parts,  an  upper,  the  sub-acrouiial  bursa, 
and  a  lower,  the  sub-deltoid  bursa  proper. 

How  can  we  distinguish  between  an  effusion  into  this  bursa  and 
an  effusion  into  the  joint  ? 

In  the  first  place,  by  inspection.  If  the  sub-deltoid  bursa  is  filled 
up,  it  raises  the  deltoid  muscle  from  off  the  joint  and  the  humerus, 
especially  at  its  external  and  anterior  portions.  Klister  has  pointed 
out  that  this  bulging  is  best  recognized  by  looking  at  the  patient  from 
behind  and  above,  and  comparing  the  two  shoulders.  On  the  other 
hand,  an  intra-articular  effusion  does  not  make  the  curve  of  the 
shoulder  any  more  pronounced,  because  even  a  tensely  filled  capsule 
is  unable,  for  anatomical  reasons,  to  lift  up  the  deltoid  to  any  con- 
siderable extent.  If  the  deltoid  muscle  bulges  to  a  great  distance 
downwards,  an  intra-articular  effusion  is  at  once  excluded,  and  we 
must  assume  that  the  effusion  is  in  the  deltoid  bursa.  If  the  effusion 
in  the  joint  is  so  great  that  it  causes  a  visible  swelling,  this  swelling 
will  also  manifest  itself  where  the  joint  is  least  covered  by  muscles, 
i.e.,  in  the  posterior  region,  and  also  in  the  diverticulum  of  the  capsule 
along  the  biceps  tendon. 

This  does  not  imply  that  the  shoulder-joint  which  contains  an 
effusion  does  not  appear  to  project  away  from  the  body  more  than 
on  the  healthy  side.  But  this  is  due  to  the  fact  that  an  extensive 
effusion  presses  the  humerus  and  all  that  covers  it  somewhat  away 
from  the  body.  This  broadening  of  the  shoulder,  as  seen  from  the 
front  is,  however,  quite  different  from  the  protuberant  bulging  just 
described  in  connection  with  effusion  mto  the  bursa.  The  outline 
of  the  shoulder  is  otherwise  retained. 


54^  SURGICAL   DISEASES   OF   THE   EXTREMITIES 

If,  on  palpation,  it  appears  that  it  is  something  Hke  a  tense  cushion 
under  the  deltoid  and  over  the  bone  which  causes  the  enlargement 
of  the  shoulder,  the  case  must  be  one  of  a  bursal  effusion.  But  if 
we  at  once  come  upon  the  humerus  under  a  muscle  of  normal 
thickness,  and  the  shoulder  is  nevertheless  widened,  as  seen  from 
the  front,  the  humerus  must  be  displaced  by  an  articular  effusion, 

A  bursitis  is  only  painful  on  pressure  over  the  area  of  the  bursa, 
but  an  arthritis  is  painful  over  the  whole  extent  of  the  joint,  especially 
if  pressure  is  made  directly  over  the  capsule,  i.e.,  at  its  posterior  and 
inferior  regions. 

Loss  of  power  is  another  piece  of  evidence  in  favour  of  disease  of 
the  joint. 

In  disease  of  the  shoulder-joint,  as  in  that  of  other  joints,  there 
IS  always  the  reflex  attempt  to  keep  the  joint  at  rest,  and  allow  its 
function,  as  far  as  possible,  to  devolve  upon  some  other  joint.  In 
the  hip  this  "muscular  fixation  "  is  at  once  manifest  as  a  limp, 
because  the  joints  of  the  lumbar  vertebra?  only  make  a  poor  substitute 
for  it.  But  in  the  shoulder,  the  joints  at  the  two  extremities  of  the 
clavicle  are  able  to  compensate  for  it,  to  a  considerable  extent,  and 
thus  conceal  the  loss  of  movement.  We  must,  therefore,  examine 
for  loss  of  power,  bearing  in  mind  the  behaviour  of  the  scapula  and 
clavicle.  In  the  ordinary  way,  the  scapula  does  not  participate  in 
the  movement  of  the  shoulder  until  the  arm  is  raised  above  the 
horizontal.  But  if  the  scapula  participates  before  the  arm  reaches 
this  level,  it  is  obvious  that  there  must  be  some  limitation  of  movement 
in  the  shoulder-joint.  A  steep  position  of  the  clavicle  and  the 
approximation  of  the  shoulder  to  the  middle  line,  also  signify  limita- 
tion of  movement.  Fig.  271  (left-sided  muscular  fixation  of  the 
shoulder-joint)  illustrates  this  latter  symptom  very  clearly.  If  this 
stiffness  is  only  occasional,  e.g.,  when  the  patient  is  tired,  or  if  it 
disappears  under  anfesthesia,  it  is  purely  of  a  muscular  nature. 
If  some  force  is  required  under  the  anaesthetic  to  overcome  the 
stiffness,  it  indicates  that  definite  changes  have  already  occurred, 
especially  contraction  of  the  capsule  and  adhesions  between  the  head 
of  the  humerus  and  the  glenoid  fossa.  If  the  joint  remains  entirely 
fixed,  even  under  the  anaesthetic,  there  are  either  very  old-standing 
fibrous  adhesions,  or  bony  ankylosis  exists. 

The  patient  chiefly  notices  this  disability,  whether  it  be  due  to  the 
muscle  or  fibrous  tissue,  in  the  movements  wherein  the  rest  of  the 
shoulder  girdle  cannot  act  as  a  substitute — e.g.,  in  adduction  of 
the  arm  to  the  middle  line  behind  the  back.  Interference  with  this 
movement  is  sometimes  the  first  complaint  in  tubercle  of  the  shoulder- 
joint. 

There  are  three  conditions  which  we  must  guard  against,  in 
•examining  the  function  of  the  shoulder-joint.  The  first  has  been 
included  under  the  general  term  of  "joint  neurosis,"  and  usually 
occurs  in  the  form  of  hysteria. 

A  "neurosis  of  a  joint"  may  occur  in  children,  especially  in  little 


TXFLAMMATORY    PROCESSES   ABOUT    THE    SHOULDEK-JOIXT 


549 


girls.  If  the  patient  has  sustained  an  accident  and  looks  forward 
to  compensation,  it  is  dignified  with  the  designation  of  "traumatic 
neurosis."  We  cannot  investigate  here  the  respective  parts  played 
ni  this  condition  bv  deliberate  exaggeration  and  by  involuntary  auto- 
suggestion. These,  no  doubt,  vary  in  different  cases.  But  the  fact 
is  that  many  patients  who  assert  that  they  can  hardly  lift  their  arm 
to  the  horizontal  are  often  able,  within  a  few  minutes,  to  raise  it 
quite  vertically,  provided  that  the  neurotic  habit  is  not  too  deeply 
rooted  within  "them.  As  a  rule  there  is  no  interference  with  passive 
movements,  and  this,  of  course,  excludes  the  possibility  of  any  serious 
mjury  to  the  joint.  But  we  must  be  careful  not  to  fall  into  the  second 
source  of  error,  viz.,  a  genuine  pavahsis. 

A  workman   dislocates  his  shoulder.     It  is  promptly  reduced  by 
a  doctor,  but  still  remains  powerless  ;  the  patient  cannot  raise  his  arm. 


Fig.  271. — Approximation  of  the  level  of  the  shoulder  to  the  middle  line,  and  steep 
position  of  the  clavicle,  when  the  arms  are  raised,  signs  of  stiffness  of  the  shoulder  (early 
stage  of  arthritis  of  shoulder). 


At  first  the  doctor  thinks  of  some  damage  to  the  joint  through  the 
injur}-.  Then  he  thinks  that  the  patient  may  be  malingering,  because 
the  passive  movements  are  quite  free.  Examination,  however,  shows 
that  the  deltoid  does  not  contract  at  all  when  the  movements  are  being 
tested,  and  that  the  reaction  of  degeneration  is  present.  The  patient 
has,  therefore,  sustained  a  paralysis  of  the  circnintiex  nerve,  as  a  result 
of  his  dislocation. 

^lalingerers  and  hysterical  patients  usuallv  contract  their  muscle 
somewhat,  in  order  to  show  their  "  good  intentions " ;  whereas  in 
paralysis  this  is  impossible.  But  paresis  may  cause  great  difficulty, 
because  a  certain  amount  of  voIuntar\^  contraction  occurs,  just  as  in 
malingering.  We  can  generally  escape  from  this  difficultv,  however, 
bv  examining  with  the   faradic  and   galvanic  currents,  and  by  testing 


55°  SURGICAL   DISEASES    OF   THE    EXTREMITIES 

the  sensation  in  the  area  supphed  by  the  circumflex  nerve — i.e.,  over 
the  deltoid  muscle. 

If  we  base  our  differential  diagnosis  between  bursitis  and  arthritis 
of  the  shoulder-joint  on  what  has  already  been  said,  it  will  follow 
that  the  only  movement  which  is  hindered  in  bursitis  is  the  one 
wherein  the  inflamed  bursa  is  compressed  between  the  acromion  and 
the  humerus — i.e.,  raising  the  arm  from  the  side  ;  the  other  move- 
ments are  quite  free.  But  when  the  joint  itself  is  inflamed  and  its 
function  is  interfered  with,  all  the  movements  are  more  or  less  limited, 
both  active  and  passive. 

Finally,  it  should  be  mentioned  that  infiainuiatorx  changes  in  the 
nxiila  (lymphadenitis)  may  also  interfere  with  the  movements  of  the 
joint. 

i5.— DIAGNOSIS    OF   THE    VARIOUS    FORMS   OF    BURSITIS 
AND    ARTHRITIS    OF  THE  SHOULDER. 

(1)   BURSITIS. 

In  rare  instances  acute  infections,  like  gonorrhoea,  acute  articular 
rheumatism  and  staphylococcic  infections  (furuncle),  &c.,  may  give  rise 
to  bursitis  by  metastasis.  The  most  frequent  forms  are,  however,  the 
traumatic  and  the  tubercular.  If  the  disease  appears  directly  after 
a  contusion  of  the  shoulder,  or  after  the  constant  repetition  of  a  slight 
trauma — including  any  unaccustomed  work  which  involves  the  deltoid 
muscle — we  may  assume  that  it  has  a  traumatic  origin.  But  if  there 
has  been  a  considerable  free  interval  between  the  injury  and  the  onset 
of  the  bursitis,  or  if  the  disease  has  come  on  gradually  and  quite 
spontaneously,  we  must  think  of  tubercle,  especially  if  this  is  supported 
by  a  hereditary  predisposition,  and  by  the  previous  history  of  the 
patient. 

Occasionally  the  bursitis  is  not  primary,  but  has  been  caused  by 
the  rupture  into  the  bursa  of  an  extra-articular  focus  in  the  bone. 
Positive  information  can  only  be  furnished  by  a  skiagram. 

(2)  ARTHRITIS    OF    THE   SHOULDER. 

In  discussing  the  etiology  of  this  condition,  it  is  necessary  to 
distinguish  the  acute  from  the  chronic  cases. 

{a)  Acnte  intlnniination  of  the  shonlder-Joint  may  be  one  symptom 
of  acute  articular  rheumatism.  Such  a  case  would  be  left  to  the 
physician,  but  we  must  remember  that  there  is  a  complete  chain  of 
transitional  forms — from  the  purely  serous  polyarthritis  of  rheumatism 
to  the  suppurative  inflammation  of  pyaemia— which,  under  certain 
circumstances,  may  require  surgical  treatment.  The  most  important 
of  these  is  scarlatinal  arthritis,  which  often  attacks  the  shoulder;  and 


IXFLAMMATORY    PROCESSES   ABOUT   THE    SHOULDER-JOINT  55 1 

we  must  be  careful  lest  we  compromise  the  functions  of  the  joint 
by  delaying  incision  too  long.  Gonorrheal  arthritis  is  another 
transitional  form  between  rheumatism  and  pyaemia,  and  is  usually 
recognized  by  the  fact  that  only  one  joint  is  affected.  This  variety 
should  be  thought  of,  if  the  patient  has  outgrown  the  stage  of 
children's  ailments,  but  has  not  yet  learnt  how  to  avoid  the  gono- 
coccus.  But  one  must  never  forget  that  this  micro-organism  may 
occur  in  childhood  (especially  in  little  girls) — Gonococciis  insontinm. 
Pyaemic  arthritis  of  the  shoulder  is  mostly  met  with  in  puerperal 
infections,  but  may  occur  in  any  pyaemic  disease. 

(/))  The  diagnosis  is  much  more  difficult  in  cliroiiic  artliritis  of  the 
sliouldcr.  It  is  most  important,  from  the  therapeutic  point  of  view, 
to  decide  whether  it  is  tubercular  or  not. 

In  the  first  place  one  has  to  consider  traumatic  arthritis  of  the 
shoulder.  The  histories  of  these  cases  are  very  similar,  with  slight 
variations.  A  middle-aged  or  elderly  man  has  sustained  a  sprain 
of  the  shoulder,  or  some  severe  injury,  such  as  a  dislocation,  which 
has  been  properly  reduced.  The  patient  may,  of  course,  be  a  female, 
but  the  condition  rarely  happens  in  this  sex.  The  original  pain  dis- 
appears quite  normally,  but  there  is  no  restoration  of  the  power  of 
the  joint.  Attempts  at  movement  remain  painful,  and  they  are  often 
attended  by  creaking  and  grating.  Pain  frequently  radiates  towards 
the  back  of  the  neck  and  the  elbow.  On  examination,  it  will  be  found 
that  the  joint  is  more  or  less  stiff,  and  that  the  capsule  is  distinctly 
painful  on  pressure  ;  but  there  is  not  sufficient  effusion  to  permit  of 
recognition.  If  untreated,  the  condition  may  persist  for  weeks  and 
months,  but  in  slight  cases  it  rapidly  yields  to  proper  treatment, 
especially  if  the  patient  is  otherwise  well,  and  has  not  instituted  a 
claim  for  damages.  In  old  people,  in  rheumatic  and  gouty  subjects 
this  traumatic  arthritis  of  the  shoulder  may  develop  into  one  of  the 
varieties  of  "chronic  rheumatism,"  which  proves  refractory  to  all 
treatment. 

If  this  disease  has  not  followed  the  injury,  but  has  come  on 
gradually  some  time  after  the  subsidence  of  the  immediate  effects 
of  the  accident,  we  should  think  oi  post-irauiuatic  tuberculosis. 

The  more  trifling  the  injury,  and  the  more  pronounced  the 
inflammatory  symptoms,  the  more  naturally  will  this  diagnosis  suggest 
itself.  Sometimes  we  can  do  nothing  but  give  a  test  injection  of  tuber- 
culin, or  wait  and  watch  the  case — which  is  equally  good.  A  skiagram 
can  only  help  the  diagnosis  if  changes  in  the  bone  have  alreadv 
occurred,  but  as  these  changes  can  never  be  excluded,  this  method  of 
examination  should  never  be  neglected.  In  such  cases,  we  may 
assume  with  the  greatest  probability  that  the  injury  has  merely  caused 
a  latent  tuberculosis  to  assert  itself. 

The  diagnosis  is  easier  if  there  has  been  no  antecedent  injury,  for 


552  SURGICAL   DISEASES   OF   THE    EXTREMITIES 

then  it  is  only  necessary  to  decide   between   tubercle   and   chronic 
articular  rheumatism. 

The  anatomical  changes  which  occur  in  this  latter  include  pro- 
cesses of  serous  effusion,  fibrous  adhesions,  proliferation,  and 
destruction — indeed,  any  morbid  change  which  may  occur  in  a  joint. 
Their  etiology  includes  injuries,  toxic  processes  (lead),  infections  (an 
original  acute  infective  rheumatism),  and  finally  neuropathies  (tabes, 
syringo-myelia)  apart  from  cases  which  we  cannot  account  for  at  all. 
It  must  be  stated,  however,  that  none  of  the  anatomical  varieties 
presupposes  any  definite  etiology  ;  one  and  the  same  cause  may  be 
responsible  for  the  most  differing  anatomical  forms. 

The  tendency  towards  the  affection  of  many  joints  in  a  symmetrical 
manner  is  an  important  diagnostic  sign,  common  to  all  varieties, 
whatever  be  their  causes — even  if  traumatic.  This  circumstance 
permits  the  diagnosis  to  be  made  at  once  in  a  large  number  of  cases. 
It  is  true  that  tubercle  often  affects  many  joints,  but,  as  a  rule,  there 
is  at  any  rate  one  focus  so  much  involved  that  there  is  no  difficulty 
about  the  diagnosis.  It  is  more  difficult  to  diagnose  the  cases  of 
subacute  or  chronic  rheumatic  polyarthritis,  wherein  several  joints 
are  attacked  at  long  intervals.  If  only  one  joint  is  diseased,  we  may 
remain  long  in  doubt.  Early  muscular  atrophy,  progressive  deteriora- 
tion— even  if  slow — depression  of  the  general  health,  and  possibly 
also  a  slight  rise  in  temperature,  would  point  to  tubercle  ;  but  a 
variable  local  condition  with  good  general  health  would  indicate 
a  "  rheumatic "  affection.  Some  weight  in  making  a  diagnosis  may 
also  be  attached  to  the  success  or  failure  of  spa-treatment  All  these 
difficulties  apply  to  those  frequent  forms  of  shoulder-joint  tubercle, 
wherein  there  is  neither  effusion  nor  any  demonstrable  swelling  of 
the  capsule,  wherein  the  morbid  process  manifests  itself  by  slow 
destruction  and  simultaneous  absorption  of  the  articular  ends  of  the 
bones — a  clinical  picture  which  used  to  be  termed  "  caries  sicca."  On 
the  other  hand,  there  can  be  no  doubt  about  the  diagnosis  of  tubercle 
if  a  localized  swelling  gradually  forms,  even  at  the  posterior  region 
of  the  joint,  with  suppurative  softening  of  the  tissues,  and  the 
formation  of  sinuses  which  discharge  their  pus  and  pieces  of  caseous 
material. 

Gummatous  disease  of  the  shoulder-joint  may  occur,  but  it  is 
so  rare  that  it  does  not  enter  into  practical  consideration. 

We  may  now  briefly  summarize  the  foregoing  : — 

//  the  signs  of  infiamniation  of  the  shoulder — loss  of  power,  spon- 
taneous pain,  tenderness  on  pressure — coiiie  on  immediately  after  an 
injury,  we  may  assume  the  presence  of  a  purely  traumatic  arthritis  of 
tJie  shoulder-joint,  even  if  the  malady  persists  for  weeks  or  months.  But 
if  these  symptoms  come  on  spontaneously,  or  supervene  a  few  weeks  after 
a  slight  injury,  we  should  think  of  tubercle,  especially  in  young  patients.    If 


INJURIES   ABOUT   THE   ELBOW-JOINT  553 

in  addition  to  the  slwnlder,  other  joints  become  affected  with  inflaui- 
niatory  symptoms  at  longer  or  shorter  intervals,  hut  witliout,  anyivhere, 
presenting  the  classical  signs  of  a  tubercular  focus,  the  case  probably 
represents  one  of  the  forms  of  chronic  articular  rheumatism,  and  the 
older  the  patient  is,  the  more  probable  is  this  diagnosis. 

C— PRIMARY  DISEASES  OF  THE  BONE. 

We  have  referred  to  the  bones  as  the  third  source  of  inflamma- 
tion in  the  neighbourhood  of  the  shoulder-joint.  So  far  as  the 
bone  disease  manifests  itself  in  the  form  of  in/ianiniation  of  a  joint 
the  foregoing  remarks  will  apply.  The  involvement  of  the  bone,  or 
the  presence  of  the  primary  focus  within  it  can  only  be  demonstrated 
by  a  skiagram.  But  the  bone  may  be  diseased,  and  the  joint  itself  not 
be  involved.  This  condition  will  be  suggested,  when  there  are  pain 
and  swelling  in  the  neighbourhood  of  the  joint,  while  its  movements 
remain  free.  The  localization  of  the  changes  will,  at  once,  enable 
us  to  distinguish  wdiether  the  disease  originates  in  the  scapula  or 
the  humerus,  and  its  course  generally  enables  us  to  determine  whether 
it  is  acute  osteomyelitis,  tubercle  or  gumma.  In  its  early  stages,  a 
sarcoma  may  be  confused  with  a  chronic  inflammatory  disease. 


CHAPTER   LXXXIII. 
INJURIES  ABOUT  THE  ELBOW-JOINT. 

Although  the  elbow-joint  is  superficial  in  position  and  easily 
felt,  injuries  thereof  are  a  source  of  great  perplexity  of  diagnosis. 
There  are  two  reasons  for  this ;  firstly,  the  fact  that  three  bones 
participate  in  the  construction  of  the  joint,  and  secondly,  the 
extensive  swelling  of  the  soft  parts  which  occurs — much  more 
extensive,  for  example,  than  in  the  case  of  the  wrist.  But  if  we 
accustotn  ourselves  to  draw  logical  conclusions  from  what  is 
actually  felt,  we  shall  find  that  the  undiagnosable  injuries  about 
the  elbow  will  tend  to  become  fewer  and  fewer. 

Having  decided  from  the  loss  of  power  and  deformity  that  some 
severe  injury  to  the  elbow  has  occurred,  we  must  first  d  termine 
whether  a  fracture  or  a  dislocation  is  present,  and  then  the  variety 
of  the  one  or  the  other. 

Some    indications    are    furnished     by    the    ^^6'    of     the    patient. 


554. 


SURGICAL   DISEASES   OF   THE   EXTREMITIES 


Fractures  and  separation  of  the  epiphyses,  with  secondary  disloca- 
tions, are  more  apt  to  occur  m  early  childhood,  whereas  adults  are 
more  subject  to  pure  dislocation,  because  of  the  relatively  greater 
firmness  of  their  bones. 

We  will  now  proceed  to  detail  the  method  of  examination. 


/!.— INSPECTION. 

Sometimes  a  mere  glance  suffices  for  the  diagnosis.  If  the  out- 
lines of  the  sigmoid  fossa  are  visible  through  the  skin  of  a  thin 
individual  and  the  head  of    the  radius  projects    behind,  no  one  can 

doubt  the  existence  of 
a  dislocation  (fig.  272). 
If  the  axis  of  the  fore- 
arm, as  seen  from  the 
front,  instead  of  deviat- 
ing slightly  externally  is 
directed  internally,  we 
immediately  think  of 
certain  forms  of  fracture 
(fig.  287),  &c. 

On  inspection,  we 
note  the  following 
points,  which  we  shall 
make  further  use  of,  in 
the  course  of  examina- 
tion. 

(i)   Position    of    the 
elbow    (flexion    or    ex- 
tension,   abduction     or 
adduction,   pronation 
or  supination,  abnormal 
position  of  the  axis    of 
arm    or    forearm).      (2) 
Degree  of  the  swelling.    (3)  Prominence  of  the  bony  parts.    (4)  Ecchy- 
moses.     (5)  Impalement  of  the  skin.    (6)  Posture  of  the  hand  (paralysis 
of  the  radial  nerve). 

5.— EXAMINATION  OF    ELBOW  MOVEMENTS. 

We  first  ask  the  patient  to  carry  out  a  few  movements  in 
various  directions.  If  he  complies  with  our  request,  and  the  move- 
ments attain  the  normal  range,  he  has  neither  a  dislocation  nor  a 
fracture  which  interferes  with  the  mechanism  of  the  joint.  If  active 
movements  are  restricted,  we  must  endeavour  to  ascertain  the  icxtent 


Fig.  272. — Backward  dislocation  of  elbow. 


INJURIES   ABOUT   THE   ELBOW-JOINT 


555 


of  the  passive  movements,  at  first,  gently  without  anaesthesia,  and 
then,  if  necessary,  under  an  anaesthetic.  The  following  possibilities 
have  to  be  considered  : — 

{a)  If  there  be  an  excessive  amount  of  movement  in  one  definite 
direction,  while  movement  in  the  opposite  direction  is  restricted  by 
the  tension  of  the  uninjured  ligaments,  we  may  conclude  that  a 
sprain  has  occurred. 

In  posterior  or  postero-external  dislocations,  which  constitute 
the  majority  of  these  cases,  it  is  possible  to  over-extend  the  elbow, 
but  it  is  not  possible  to  flex  it  beyond  a  right  angle.  In  pure  lateral 
dislocations  flexion  is 
indeed  possible,  but  the 
aspect  of  the  joint,  as 
seen  from  the  front,  with 
the  lateral  displacement 
of  the  forearm  in  relation 
to  the  humerus  (the  bay- 
onet shape  of  the  arm)  is 
so  striking,  that  the  dis- 
location of  the  joint  can- 
not be  missed.  We  must, 
however,  decide  whether 
it-  is  a  complete  or  in- 
complete backward  dislo- 
cation, or  a  dislocation 
backwards  and  outwards, 
or  the  rare  backward  and 
inward  form,  or  the  still 
more  rare  backward  dis- 
location of  the  ulna  only. 
Careful  palpation  of  the 
projecting  bony  land- 
marks will  furnish  infor- 
mation on  all  these  points. 


Fig.  273. 


-Dislocation  of  elbow  backwards.     Skiagram 
of  fig.  272. 


(6)  If  our  examination  has  showai  that  there  is  no  interference  witli 
passive  extension  and  flexion,  thus  excluding  the  possibility  of  any 
ordinary  dislocation,  the  case  is  one  of  fracture,  or  there  may  be  no 
severe  injury  at  all. 

Before  coming  to  any  definite  conclusion  and  diagnosing  the 
exact  form  of  fracture,  it  is  desirable  to  recall  the  possible  varieties 
by  a  glance  at  the  accompanying  diagrammatic  illustration  (fig.  274). 

The  skiagrams  which  follow  illustrate  again  the  most  important  and 
typical  fractures,mostly  of  children.   Owing  to  the  epiphyseal  cartilages, 
the  interpretation  of  their  skiagrams  often  presents  great  ditificulties. 
36 


556 


SURGICAL   DISEASES   OF   THE    EXTREMITIES 


The  examination  of  the  power  of  the  elbow  and  the  testing  for 
false  mobility  m.ay  yield  the  following  possibilities  : — 

(i)  //  all  passive  niovenients  are  free,  and  the  only  derangement 
consists  of  the  ■unpossihility  of  active  extension,  it  is  obvious  that  some 
break  has  occurred  in  the  continuity  of  the  extension  apparatus,  and 
experience  shows  that  this  usually  indicates  a  fracture  of  the 
olecranon  (fig.  277). 

If,  anticipating  the  order  of  the  examination,  we  palpate  its 
surface,  and  come  upon  a  gap  in  the  bone,  or  find  thereon  a  trans- 
verse, sensitive  groove,  the  diagnosis  is  confirmed.  If  doubt  still 
remains,  the  attempt  should  be  made  to  displace  the  tip  of  the 
olecranon  from  the  ulna — a  manoeuvre  which  is  very  painful  for 
the  patient. 

It  is  obvious  that  the  examination  for  active  extension  must  be 
conducted  in  such  a  way  that  the  drop  of    the  forearm  by  its  own 


Fig.  274. --Course  of  the  lines  of  fractures  at  the  lower  end  oi  the  humerus. 


1.  Fracture  of  the  external  epicondyle. 

2.  Fracture  of  the  rotula. 

3.  Fracture  of  the  external  condyle. 

4.  Fracture  of  the  internal  condyle. 


5.  Fracture  of  the  internal  epicondyle. 

6.  Fracture  through  the  condyles. 

7.  Fracture  above  the  condyles. 

8.  Y-shaped  fracture. 


weight  should  not  mislead  the  observer  into  thinking  that  active 
extension  has  been  performed. 

(2)  If  the  olecranon  is  uninjured,  the  forearm,  which  is  usually 
flexed  to  a  right  angle,  should  be  moved  backwards  and  fonvards  in 
relation  to  the  humerus.  If  this  is  possible,  and  if  the  epicondyles 
are  felt  to  move  witJi  the  olecranon,  there  must  be  a  break  in  the 
continuity  above  the  joint,  i.e.,  a  supra-condylar  fracture. 

If,  on  displacing  the  olecranon  backwards,  it  gets  into  the  position 
of  a  posterior  dislocation,  hut  the  epicondyles  do  not  follow  it,  and 
if  it  can  easily  be  replaced  into  its  normal  position,  we  should  think 
of  fracture  of  the  coronoid  process  of  the  ulna,  especially  if  these 
movements  are  associated  with  some  crepitus.  Tliis  fracture  was 
rarely   recognized    before   the   advent  of    X-rays,  but  the  light  now 


INJURIES   ABOUT   THE   ELBOW-JOINT 


557 


shed  thereon  renders  the  diagnosis  possible  in  the  future  even  without 
the  rays.  The  signs  just  noted  ought  always  to  raise  the  suspicion  of 
the  very  rare  fracture  of  the  base  of  the  coronoid  process.  We  shall 
describe  a  somewhat  more  frequent  form  later  on. 

(3)   If  we  cannot  move  the  fore- 
'     !         arm     backwards    and    forwards    in 
I         relation  to  the    humerus,    we    must 
examine  for  another  important  sign, 


Fig.  275. — Normal  elbow  taken  from 
behind.  Boy  aged  11.  ^.?'.  =  centre  of 
ossification  of  epicondyle.  C£.  =  exlernal 
condyle.  The  centre  of  ossification  of 
internal  condyle  is  not  yet  present. 


Fig.  276.  —Normal  elbow  taken  from  the 
side.  Boy  aged  11.  References  as  in 
previous  figure. 


i.e.,  for  abnormal  lateral  mobility,  in 
the  sense  of  adduction  or  abduction. 

As  there  is  always  a  certain 
amount  of  abduction  atid  adduction 
normally  possible  in  children,  it  is 
necessary  to  compare  the  injured  side 
witli  the  uninjured  one.  The  forearm 
makes  an  obtuse  angle  with  the  arm, 
the  angle  being  open  outwards,  thus 
constituting  a  slight  degree  of  valgus, 
as  in  the  knee.  This  valgus  posture 
is  more  pronounced  in  females  than 
in  males. 

If,  on  comparing  the  two  sides 
when  both  arms  are  kept  in  the 
same  attitude,  it  is  seen  that  the 
normal  abduction  is  lost  on  the 
injured  side  (fig.  284),  or,  indeed, 
replaced  by  a  position  of  adduction. 


Fig.  277. — I^'raclure  of  the  olecranon. 


558 


SURGICAL   DISEASES   OF   THE   EXTREMITIES 


Fn 


Oe. 


Fig.  278. — Supracondylar  fracture  with- 
out dislocation  (/^.r.).  Boy  aged  12.  The 
internal  epicondyle  has  fused  wiih  the 
humerus  (unusually  early).  The  centres  of 
ossification  for  the  internal  condyle  {C.i.), 
and  the  olecranon  [O.I.),  have  appeared. 


Fig.  279.  —  Same  case  as  previous  figure, 
from  the  side.  F.r.  i=r  line  of  fracture  with 
small  piece  separately  broken  off  at  the  back. 


Fig.  280. — Supra-condylar  fiacture  (hyperexten- 
sion  fracture)  in  a  girl  aged  3,  taken  from  the  side, 
showing  the  backward  displacemen'. 


281. — Same  case,  taken  from  the  side,  showing, 
lateral  displacement  (bayonet  shape). 


INJURIES   ABOUT   THE   ELBOW-JOINT 


559 


we  can  at  once  conclude  that  there  is  abnormal  lateral  mobility. 
Passive  movements  will  show  whether  this  increased  mobility  is 
present  in  both  directions,  or  only  in  one  direction.  In  the  former 
case  the  condition  must 
be  one  of  supra-condv- 
lar  fracture,  which  we 
have  already  recognized 
by  the  fact  that  the  fore- 
arm can  be  displaced 
from  before  backwards. 
In  the  latter  case  the 
condition  must  be  one 
of  damage  to  the  liga- 
ments of  one  side,  not, 
as  a  rule,  merely  a 
simple  rupture  of  a  lig- 
ament, but  a  fracture 
of  the  portion  of  bone 
into  which  the  ligament 
is  inserted,  i.e.,  the  in- 
ternal or  external  condyle 
or  the  epicondvle.  If 
ulnar  adduction  is  in- 
creased, the  external 
radial  lateral  ligament 
must  have  given  way,  or 
the  external  condyle  may  have  been  torn  off  with  it  (figs.  289  and  290). 
On  the  other  hand,  increased  abduction  signifies  the  tearing  off  or 
the  internal  epicondyle  (figs.  285,  286,  287),  or  the  much  rarer 
fracture  of  the  internal  condyle. 

(4)   But  even  this  examination  may  fail  to  give 
us  an  unequivocal  result.     It  may  be  possible  to 
displace  the  forearm  to  some  extent,  both  back- 
wards   and    forwards,    there    may    be    increased 
mobility    in    the     direction    of    abduction    and 
adduction,    but    not    one    of    these    signs    may 
be   sufificiently  pronounced   to   base  a  diagnosis 
thereon.     We  must  therefore  make  one  final  test 
by  firmly  grasping  the  humerus   at  the  epicon- 
dyles,  and  attempting  to  move  the  bones  of  the 
forearm,  at  the  elbow  joint,  in  a  lateral  direction. 
The  object  of  this  manoeuvre  is  not  to  bring  the  forearm  to  an  angle 
with  the  humerus,  but  to  displace  it  into  a  direction  parallel  therewith. 
If  we  can  do  this,  it  is  very  probable  that  a  piece  of  bone   consisting 


Fig.    282. — Supra-condylar  fracture  (flexion  fracture), 
in  a  boy  aged  lo.     Lower  fragment  displaced  to  the  front. 


Fig.  283. — Piece  of 
cartilage  bone  broken  off 
the  rotula  ((/".  fig.  291). 


560  SURGICAL   DISEASES    OF   THE    EXTREMITIES 

of  the  trochlea  and  rotnla  has  been  broken  off ;  in  other  words,  that 
a  fracture  through  the  condyles  has  been  sustained. 

It  is  very  Hkely  that  this  movement  may  be  effected  in  the  case  of 
other  fractures  which  extend  into  the  joint,  especially  in  fractures 
of  the  condyles  ;  but  these  have  already  been  recognized  by  the 
abnormal  degree  of  adduction  or  abduction  of  which  they  are 
capable. 

(5)  Even  if  this  test  is  negative,  we  cannot  definitely  exclude  injury 
of  one  of  the  bones  forming  the  joint.  There  still  mav  be  a  circuui- 
scrihed piece  of  bone  broken  off,  iviihin  ilie  Joint,  which  does  not  interfere 
with  passive  movements.  Two  symptoms  will  lead  to  this  assumption  : 
(i)  the  presence  of  crepitus  when  free  movements  are  made,  and  (2) 
sudden  temporary  interference  wiLh  these  movements.  We  conclude 
irom  the  crepitus  that  something  is  broken,  and  the  sudden  inter- 
ference with  movement,  as  occurs  Avhen  a  loose  bodv  is  in  a  joint, 
shows  that  some  solid  substance  becomes  incarcerated  between  the 
ends  of  the  bones  (fig.  283).  Further  conclusions  may  be  drawn  from 
palpation. 

C— PALPATION. 

This  will  aid  us  in  solving  the  problems  which  have  not  been 
cleared  up  by  inspection  and  by  testing  the  movement  of  the  joint. 
Palpation  is  easy  when  the  case  is  recent  and  the  swelling  is  slight  ; 
but  it  may  be  quite  valueless  if  some  time  has  elapsed  since  the 
accident,  and  the  joint  has  become  tense  with  effused  blood  and  its 
whole  neighbourhood  extensively  infiltrated.  In  these  circumstances 
we  must  have  recourse  to  anaesthesia,  and  massage  the  oedema  awav  as 
far  as  possible,  before  making  the  examination.  It  is  most  important 
to  determine  whether  the  swelling  is  situated  within  the  joint  or  out- 
side the  capsule.  If  the  latter  be  the  case,  it  is  in  favour  of  a  para- 
articular fracture  (supra-condylar). 

This  happened  in  the  case  illustrated  in  ligs.  278  and  279.  There 
was  no  false  mobility  and  it  was  only  the  circumscribed  swelling  and 
pain  on  pressure  which  made  one  suspect  a  "  fracture  of  the  bone 
above  the  joint." 

We  have  next  to  feel  the  three  well-known  bony  landmarks,  viz., 
the  tip  of  the  olecranon  and  the  two  epicondyles. 

We  know  from  anatomy  that  these  three  points  form  an  equilateral 
triangle  (fig.  288  (b)  and  (c))  lying  in  the  same  plane  as  the  humerus, 
when  the  arm  is  flexed  to  a  right  angle,  whereas  they  are  all  at  the 
same  level,  or,  mathematically  speaking,  in  a  plane  vertical  to  the 
humerus  (fig.  288  (a)),  when  the  arm  is  extended.  It  is  always  advisable 
to  compare  the  injured  with  the  uninjured  side,  while  making!  the 
examination,  in  order  the  better  to  appreciate  slight  changes  in  these 
relations. 

The  following  possibilities  must  be  taken  into  consideration  : — 


INJURIES   ABOUT   THE   ELBOW-JOINT 


561 


(i)  If  the  tip  of  the  olecranon  is  displaced  iipivavds  when  the  arm  is 
extended,  or  displaced  backwards  when  the  arm  is  flexed,  i.e.,  has 
shifted  from  the  plane  of  the  humerus,  whereas  the  epicondyles  retain 
their  relation  to  this  bone,  the  case  is  either  one  of  backward  disloca- 
tion or  fracture  through  the  condyles.  Marked  projection  of  the 
olecranon,  combined  with  limitation  of  movement — impossibility  of 
complete  flexion — points  to  dislocation. 

Slight  projection  with  free  passive  movement  indicates  fracture 
through  the  condyles,  which  is  rare,  or  detachment  of  the  coronoid 
process,  which  is  equally  rare. 

If  the  projecting  olecra- 
non, notwithstanding  its 
backward  displacement,  still 
remains  midway  between  the 
external  and  internal  epicon- 
dvle,  the  case  is  one  of  simple 
posterior  dislocation.  If  we 
can  distinctly  palpate  the  sig- 
moid fossa  and  the  head  of 
the  radius,  the  dislocation  is 
complete  ;  in  other  cases  it 
is  incomplete.  If  the  head 
of  the  radius  remains,  how- 
ever, in  its  normal  position, 
or  slightly  displaced  inwards, 
the  case  is  an  example  of  the 
rare  posterior  dislocation  of 
the  ulna  alone. 

(2)  If  the  tip  of  the  ole- 
cranon ami  epicondyles  are 
together  displaced  hackivards 
in  regard  to  the  plane  of  the 
shaft  of  the  humerus,  so  tiiat 
the  relation  of  the  epicon- 
dyles to  the  shaft  of  the  hu- 
merus is  altered,  and  so  that 
they  are  movable  against  the 

humerus,  the  case  can  only  be  a  supracondylar  fracture— a  hyper- 
extension  fracture,  whose  course  runs  from  forward  and  below  to 
behind  and  above  (lig.  280). 

(3)  If  the  olecranon  alone,  without  the  epicondyles,  is  displaced 
fonvards  and  movement  is  limited  it  must  be  one  of  the  rare  cases  of 
anterior  dislocation  ;  if  passive  mobility  is  free,  and  the  epicondyles 
are  displaced  forwards   at  the  same  tune,  the  case   must  be   one  of 


Fig.  2S4. — Rijiht  supra-condylar  fracture,  in 
a  boy  aged  ii.  The  normal  cubitus  valgus  is 
straightened  out  (angle  very  definite  on  left  side). 
Shortening. 


562 


SURGICAL   DISEASES   OF   THE   EXTREMITIES 


supracondylar  fracture,  arising  through  flexion  (fig.  282).  In  the 
latter  case  it  may  be  possible  to  feel  the  pointed  end  of  the  upper 
fragment  of  the  humerus  through  the  soft  parts  above  the  olecranon, 
if  there  is  not  too  much  swelhng,  and  we  may  also  be  struck  by  the 
unusual  rotundity  of  the  elbow  in  profile. 

(4)  If  the  olecranon  appears  to  be  displaced  laterally  in  relation  to 
the  epicondyles,  we  must  note  whether  this  displacement  is  in  relation 
to  both  condyles.  If  it  is  so,  there  must  be  an  incomplete  or  complete 
lateral   or  postero-lateral    dislocation,  according  to   the   degree  of 

ligamentous    rupture     and     displace- 
^        ment. 

(5)   If    the    tip    of    the    olecranon 
1        only     preserves    its     normal    relation 


Fig.  285. — Detachment  of  internal 
epicondyle  and  its  displacement  to- 
wards \he  forearm. 


Fig.  286.— Detachment  of  internal  epicondyle 
without  displacement.  The  slight  indication  of 
callus  shows,  apart  from  the  age  of  the  patient, 
that  it  is  not  merely  physiological  cartilage. 


in  regard  to  one  epicondyle,  we  must  assume  that  the  other  condyle 
or  epicondyle  has  been  broken  off  and  displaced.  The  epicondyle 
is  usually  broken  off  by  itself  on  the  inner  side,  whereas  on  the  outer 
side  it  is  generally  a  matter  of  fracture  of  the  condyle.  The  symptoms, 
in  regard  to  false  mobility,  are,  in  principle,  the  same  in  both  cases; 
hyperabduction  when  the  fracture  is  on  the  inner  side,  and  hyper- 
adduction  when  the  fracture  is  on  the  outer  side.  If  the  swelling 
is   not  too  great,  palpation   is  quite   conclusive.      On  the  outer  side 


INJURIES   ABOUT   THE    ELBOW-JOINT 


563 


we  often  find  the  detached  condyle  rotated  to  the  extent  of  90°  or 
even  180°. 

In  fracture  of  the  internal  epicondyle  the  detached  piece  of  bone 
is  sometimes  found  hanging 
from  the  lateral  ligament  in 
its  normal  position,  but  often 
towards  the  anterior  surface, 
and  displaced  even  as  far  as 
the  level  of  the  fold  of  the 
joint  (fig.  285). 

(6)  If  we  feel  the  three 
chief  points  in  their  proper 
position,  but  the  head  of  the 
radius  is  displaced,  there  must 
be  a  dislocation  of  tiie  radius 
alone.  The  radius  usually 
deviates  forward  (fig.  293)  or 
outwards,  rarely  backwards, 
and  the  injury  generally  oc- 
curs in  children  as  a  result  of 
extreme  pronation  combined 
with  abduction.  The  so-called 
subluxation  of  the  radius 
forwards,  which  is  also  fre- 
quent in  children,  must  be 
distinguished    from    complete 

dislocation  of  the  radius.  This  is  at  present  looked  upon  as  an  mter- 
position  of  the  posterior  wall  of  the  capsule  between  the  radius  and 
liumerus. 

This  injury  often   occurs  to  children,  when  they  are  dragged  by 


Fig.    287. — Detachment  of  internal  epicondyle, 
and  its  rotation  to  the  extent  of  90°. 


$h^ 


Fig.  288. — Relative  positions  of  three  bony  projections  on  elbow,  which  serve  as 

landmarks, 
(a)  Extension.  (b)  Flexion  as  seen  from  Ijeliind.         (c)  Flexion  as  seen  from  the  side. 


564 


SURGICAL   DISEASES   OF   THE    EXTREMITIES 


the  arm.  On  palpation  nothing  can  be  found,  in  striking  contrast 
to  the  incapabiHty  of  performing  anv  movement.  The  accuracy  of 
the  diagnosis  is  proved  by  the  result  of  treatment;  power  of  movement 
is  at  once  regained  if  the  normal  conditions  are  restored  by  supination 
and  flexion. 

(7)  There  may  be  pronounced  posterior  displacement  of  the  fore- 
arm, when  considerable  passive  movement  is  applied  to  it.  At  the 
same  time  each  separate  condyle  can  be  displaced  from  the  shaft 
of  the  humerus.  The  movements  are  accompanied  by  a  sound  of 
crackling  like  a  bag  of  nuts,  in  the  joint,  which  is  filled  with  blood. 
In  these  circumstances  there  can  be  no  doubt  that  there  is  a  supra- 
condylar fracture,  combined  with  fracture  of  both  condyles  —  in 
other  words,  a  T-  or  Y-shaped 
fracture  (fig.  292).  ] 

(8)  If  the  ordinary  signs  of  a 


^  c. 


Fig.  289. — Fracture  of  external  condyle.     Seen 
from  the  side. 


Fig.  290. — Fracture  of  external  condyle.     From 
behind. 


posterior  dislocation  exist,  and  if  in  addition  crepitus  and  abnormal 
mobility  of  the  external  condyle  or  internal  epicondyle  are  noted, 
it  is  obvious  that  the  dislocation  is  associated  with  a  fracture.  This 
latter  combination  is  a  very  typical  occurrence. 

(9)  Sometimes,  nothing  may  be  recognized  at  first  on  passive 
movement  and  palpation  ;  nevertheless,  a  suspicion  of  crepitation 
being  present,  we  cannot  exclude  a  fracture.  In  some  cases,  prona- 
tion and  supination  are  deranged,  in  some  flexion  is  painful,  and  in 


INJURIES    ABOUT   THE    ELBOW-JOIXT 


565 


others  the  derangements  vary  so  much  that  they  suggest  a  "  derange- 
ment interne" — although  this  is  not  a  diagnosis. 

(a)  If  there  is  locaHzed  pain  on  pressure  over  the  head  of  the 
radius,  if  it  is  thickened  and  abnormally  prominent,  with  a  circum- 
scribed effusion  of  blood  in  its  vicinity,  if  pronation  and  supination 
are  painful  and  if  thev  are  accompanied  by  rotation  of  the  head  of  the 
radius,  the  case  is  one  of  fracture  of  the  head  itself  (chisel  fracture, 
Bniiis ;  fig.  294).  But  if  the  pain  on  pressure  is  mainly  limited  to  the 
neck,  there  is  probablv  a  fracture  of  the  neck,  whether  the  head 
moves  on  rotation  or  not  (hg.  295).  The  detached  head  is  sometimes 
turned  to  an  angle  of  90°,  so  that  its  depression  can  be  felt. 

{h)  If  the  symptoms  of 
a  foreign  body  in  a  joint 
are  the  most  prominent 
combined  with  some  limi- 
tation of  extension,  we 
should  think  of  an  abra- 
sion fracture  of  the  emi- 
nentia    capitata     humeri, 


Fig.  291. — Detachment  of 
cartilage  and  some  bone  (X) 
from  the  eminentia  capitata 
humeri  (see  corresponding 
fragment  in  fig.  283). 


Fig.  292. — T-fracture  of  lower  end  of  humerus. 


which  was  first  carefully  described  by  Kocher.  In  this  fracture,  only 
a  localized  piece  of  cartilage  with  a  small  fragment  of  bone  are  broken 
off  (fig.  283).  This  piece  may  sometimes  be  felt  as  a  loose  body, 
between  the  external  condyle  and  the  head  of  the  radius,  as  soon  as 
the  arm  is  extended.  On  flexion,  the  piece  of  cartilage  disappears 
within  the  joint. 

If  some  bone  is  detached  with  the  cartilage,  the  diagnosis  can  also 
be  made  by  X-rays  (fig.  291). 

(c)   But  if  nothing  is  found,  except  that  there  is  localized  pain  on 


566 


SURGICAL   DISEASES   OF   THE    EXTREMITIES 


pressure  and  ecchymosis  of  the  elbow,  we  may  assume  that  there  is  a 
detachment  of  the  coronoid  process.     As  soon  as  callus  develops,  it 
is  very  easy  to   detect  this  injury  by 
palpation  (ng.  296). 

The  diagnosis  of  "  sprain  "  is  only 
justified  if  an  exhaustive  and  systematic 
examination  fails  to  elicit  anything 
definite. 


Fig.  293. — Forward  dislocation  of  radius  alone. 


Fig.  294. — Chisel  fracture  of  head 
of  radius. 


Fig.    295. — Detachment   of  head  of 
radius. 


Fig.  296. — Detached  fracture  of  the 
coronoid  process  of  ulna,  (c)  Prolifera- 
tion of  callus  visible  above  the  fragment. 


INJUKIES    ABOUT   THE    ELBOW-JOINT 


5^7 


D.—ROKTGEK    RAY  EXAMINATION. 

We  must  never  be  content  merely  with  a  screen  examination.  The 
clearest  picture  on  a  screen  fails  to  exhibit  the  details  which 
a  moderately  good  skiagram  shows.  It  is  impossible  to  avoid  over- 
looking on  a  screen,  subordinate,  though  important,  injuries  which 
may  accompany  the  chief  injury,  e.g.,  a  dislocation — an  injury  whicli 
is  recognizable  even  without  X-ray  examination.  Another  precaution 
which  must  be  observed,  especially  when  dealing  with  growing 
individuals,  is  always  to  take  a  control  picture  of  ilie  unhijured  side, 
in  the  same  position  as  that  in  which  we  have  examined  the  injured 
side.  If  this  is  neglected,  we  are  liable  to  interpret  the  cartilaginous 
ends  between  the  various  centres  of  ossification  as  fractures  of  the 
external  condyle,  the  olecranon,  &c.,  and  in  all  probability  we  will 
overlook  actually  existing  injuries.  It  is  also  indispensable  to  examine 
the  joint  in  two  directions  perpendicularly  to  one  another,  from  the  front 
and  from  the  side.  The  X-ray  examination  of  an  elbow  injury  is 
therefore  not  always  an  easy  task,  and  the  correct  interpretation  of 
the  skiagram  may  be  just  as  difficult  as  the  accurate  appreciation  of 
what  is  found  on  palpation. 

We  may  summarize  the  above  in  the  following  scheme — 


/Moderate  and  transitory  loss  of 
power  ;  nothing  severe  ;  pain 
on  pressure  ;  usually  a  little 
effusion- 
Ditto,  but  severe  pain  on  pres- 
sure over  the  head  of  the 
radius  or  its  neck.  The  head 
often  appears  to  be  somewhat 
thickened  ;  localized  ha;ma- 
torna  in  its  neighbourhood. 

As  in  I,  but  severe  pain  on 
pressure  in  the  flexure  of 
elbow  ;  possibly  also  swell- 
ing and  crepitus  therein  ;  loss 
of  power  of  active  flexion 
(brach.  internus  muscle). 

No    displacement   of    the   cardinal    landmarks  I  Joint  free,  but  pain  on  pressure 
(except  sometimes  in  7,  when  the  olecranon  ;      transversely  above  it. 
is  movable). 

Loss  of  power  variable  ;  sym- 
ptoms of  foreign  body  in 
joint  ;  loose  body  to  be  felt 
between  rotula  and  head  of 
radius,  on  extension. 

Severe  loss  of  power  and  effu- 
sion ;  forearm  can  be  dis- 
placed somewhat,  forwards 
and  backwards  (in  position  of 
dislocation).  Some  lateral 
displacement  also  possible. 

Passive  movements  free  ;  active 
movements  restrained  ;  ole- 
cranon mov-able,  sometimes 
proximally  displaced. 


(i)  Sprain. 


(2)  Fracture  of  the  capl- 
tulum  of  the  radius 

(or   detachment   of  the 
head). 


(3)  Fracture  of  coronoid 
process  of  ulna. 


(4)  Supracondylar     frac- 
ture without  displace- 


(5)  Abrasion      of     emin- 
entia  capltata. 


(6)  Fracture  through  the 
condyles. 


(7)  Fracture     of     ole- 
cranon. 


568 


SURGICAL   DISEASES    OF   THE   EXTREMITIES 


Olecranon  displaced  in 
relation  to  the  axis  of  ! 
the  humerus,  but  not  j 
movable  in  relation  tO( 
the  ulna.  The  epic&n-\ 
dj'les  not  movable  in 
relation  to  one  another. 


Displacement  back-^ 
wards. 


Displacement 
wards. 


for- 


/Epicondyles      not      displaced  ; 
passive  flexion  restrained. 

Epicondyles  share  in  displace- 
ment, and  movable  in  relation 
to  shaft  of  humerus;  passive 
movements  free,  or  more  e.\-- 
tensive  than  normal. 

I  Epicondyles  not  displaced. 

I 

j  Epicondyles  share  in  displace- 
I  ment  forwards  ;  passive  move- 
V     ments  iree. 

Internal    epicondyle    movable; 
I     usually  displaced  distally  and 
dorsal  ly. 

Internal  condyle  movable. 


Epicondyles    or    condyles  separately  displace- 
able  in  relation  to  the  shaft  of  the  humerus. 


External  epicondyle  movable. 


External      condyle       movable, 
usually'   rotated  about  go°  to 


Both  condyles  separately  mov- 
able, in  relation  to  one  another 
and    to   the  shaft   of  the  hu- 
^     merus. 


(S)  Posterior  dislocation. 


(9)  Supracondylar  frac- 
ture in  hyperexten- 
sion. 


(10)  Dislocation    forwards 

(rare). 

(11)  Supracondylar     frac- 

ture in  flexion. 


(12)  Fracture    of    internal 
epicondyle. 


(13)  Fracture    of    internal 

condyle  (verj-  rare). 

(14)  Fracture  of   external 

epicondyle     (very 
rare). 

(15)  Fracture   of  external 

condyle. 


(16)  Y  and  T  Fractures. 


INFLAMMATORY  PROCESSES  ABOUT  THE  ELBOW. 


(1)  ACUTE    INFLAMMATORY    PROCESSES. 

Acute  inflammation  of  the  soft  tissues  about  the  elbow  may 
resemble  an  acute  arthritis,  just  as  in  other  joints.  One  should  first 
think  of  phlegmon  of  the  forearm,  originating  from  a  lymphangitis, 
which  is   so  frequently  the  result  of  infected  wounds   of  the   hand. 

The  etiology — i.e.,  a  peripheral  injury — at  once  indicates  the  correct 
diagnosis.  It  is  not  often  that  the  elbow-joint  is  involved  after  these 
injuries.  Apart  from  other  symptoms,  their  chronological  order  serves 
to  differentiate  a  superficial  phlegmon  from  an  acute  arthritis.  In  the 
latter,  pain  and  difficulty  in  movement  appear  first,  and  the  superficial 
changes  follow  ;  in  the  case  of  a  phlegmon,  swelling  and  redness  of 
the  skin  appear  first,  and  the  difficulty  of  movement  later  on.  If  the 
inflammation  is  limited  to  the  antero-internal  side  of  the  joint,  or  at 
least  has  arisen  in  this  situation,  we  may  conclude  with  great  prob- 
ability that  the  phlegmon  or  the  abscess  has  originated  in  the  glands 
of  tJie  dhoiv.     If  the  phlegmon  has   started  behind,   we  look  to    the 


INFLAMMATORY    PROCESSES   ABOUT   THE    ELBOW  569 

olecranon  bursa  for  its  origin.  This  bursa,  like  the  pre-patellar,  has  a 
great  tendency  to  inflammation,  and  the  sHghtest  skin  abrasion  in  its 
vicinity  suffices  to  afford  entrance  to  the  cocci  and  to  cause  an 
extensive  phlegmon  of  the  whole  of  the  back  of  tiie  elbow  region. 
The  more  acute  the  process,  the  further  it  encroaches  beyond  the 
immediate  hmits  of  the  bursa,  and  extends  to  the  front  and  to  the 
upper  arm. 

In  contrast  to  this  superficial  inflammation,  which  at  any  rate  at 
first  leaves  one  side  of  the  joint  free,  in  acute  arthritis  the  entire 
circumference  of  the  joint  is  painful  on  pressure.  The  swelling  is 
most  evident  where  the  capsule  is  most  superficial,  namely,  about  the 
radius  and  at  both  sides  of  the  triceps  tendon.  But  the  soft  parts  in 
front  soon  swell  up,  and  the  whole  region  of  the  joint  finally  becomes 


Fig.  297. — Tubercle  of  the  elbow.     Spindle-shaped  swelling  01  the  joint.     Slight 
depression  at  the  site  of  the  triceps  tendon. 

red  and  oedematous.     Reference  should  be  made  to  the  remarks  on 
the  shoulder-joint  for  the  causes  of  the  inflammation. 

Let  us  begin  with  the  soft  tissues.  There  are  certain  chronic  in- 
flammatory processes  on  the  arm,  the  diagnosis  of  which  is  not  clear 
at  first  sight.  Examination  shows  that  there  is  no  primary  disease 
of  the  underlying  bone,  and  no  portal  of  entry  for  organisms  is 
evident.  The  changes  consist  of  swelling  and  purulent  infiltration 
of  the  subcutaneous  tissue  and  of  the  skin,  the  brunt  of  the  aft'ection 
falling  either  on  the  one  or  the  other.  If  any  tubercular  change,  e.g., 
caries,  disease  of  the  tendon  sheath,  or  lupus,  be  found  on  the  hand, 
we  diagnose  the  condition  of  the  arm  as  one  of  tubercular  lyuiphangitis, 
with  its  sequelje,  tubercular  abscess  of  the  soft  tissues  or  tubercular 
destruction  of  the    skin.       Individuals  suffering    from    this    form    of 


570 


SURGICAL   DISEASES   OF   THE    EXTREMITIES 


Fig.  298. 


Tuberculosis  of  the  elbow. 


(a)  Diseased   side.     Cartilage  has    disappeared  ; 
bone  eaten  away,  especially  on  the  ulna. 


Fig.  299. 

(b)  Healthy  side. 


Fig.  300. — Tubercular  focus  in  ulna. 


Fig.  301. — Chronic  inflammation  of 
olecranon  bursa. 


INFLAMMATORY  PROCESSES  ABOUT  THE  ELBOW        57 1 

tubercle  have  very  little  resistance  to  the  bacillus,  and  we  therefore 
frequently  find  other  foci  of  the  disease  present. 

If  there  is  no  indication  of  this  kind,  we  should  think  of  the  purely 
metastatic  tubercle  of  the  soft  tissues,  which  is  a  rare  form,  or  of 
syphilitic  gumma,  which  is  more  likely,  or  of  actinomycosis,  which  is, 
however,  very  rare,  in  the  extremities.  Until  quite  recently  our 
diagnosis  might  have  ended  here.  But  within  recent  years  it  has 
been  shown  that  a  special  variety  of  mycelial  fungus  {Sporotrichiim 
Beurmanni)  may  cause  persistent  changes  in  the  skin,  the  deeper 
tissues  and  even  the  bones,  with  signs  intermediate  between  gumma 
and  tubercle.  This  diagnosis  of  sporotrichosis  has  been  made  in 
many  countries  in  isolated  instances  ;  but  it  can  only  be  based  on 
bacteriological  examination  of  the  pus — another  reason  for  examining 
pus,  the  origin  of  which  is  not  quite  clear. 


(2)  CHRONIC    INFLAMMATORY    PROCESSES. 

Chronic  inflammation  of  the  elbow  depends  upon  the  same  causes 
which  we  have  encountered  in  chronic  disease  of  the  shoulder-joint. 
If  several  other  joints  are  involved,  we  find  in  the  term  chronic 
articular  rheumatism,  discussed  in  that  connection,  a  convenient 
diagnosis  rather  than  a  clear  conception.  If  the  elbow  alone  is 
diseased,  it  can  hardly  be  anything  but  tubercle. 

Careful  palpation,  comparing  both  sides,  will  generally  detect  the 
capsule,  even  if  only  slightly  distended  or  swollen,  in  the  form  of  two 
symmetrical  pads  (fig.  297)  on  both  sides  of  the  triceps  tendon,  and 
as  a  transverse  pad  at  the  level  of  the  head  of  the  radius.  If  the 
capsule  is  definitely  thickened,  the  case  must  be  regarded  as  one  of 
tubercle,  even  if  there  be  not  much  interference  with  movements. 
The  axilla  must  always  be  examined  for  enlarged  glands,  although 
they  may  be  less  frequent  in  tubercular  arthritis  than  in  tubercular 
disease  of  the  skin. 

Whereas  tubercle  usually  appears  in  the  shoulder-joint  in  the  form 
of  a  dry  caries,  without  swelling  of  the  capsule  and  without  effusion, 
the  fungating  and  caseous-suppurative  forms  occur  most  frequently 
in  the  elbow,  both  being  accompanied  by  a  moderate  amount  of 
effusion.  The  joint  soon  assumes  a  spindle-form  shape,  and  the 
tendon  of  the  triceps  stretches  at  a  slight  depth  between  the  two  pads 
of  capsule  at  the  back  of  the  joint. 

It  is  but  rarely  that  the  skiagram  indicates  any  osteoporosis  (the 
purely  synovial  form).  Definite  foci  in  the  bone  (fig.  300)  or  superfi- 
cial portions  of  the  joint  eroded  away,  are  usually  seen  (fig.  298).  In 
exceptional  cases  I  have  seen  a  certain  amount  of  peri-articular 
formation  of  new  bone,  especially  when  fistulse  are  present.     If  the 

37 


572  SURGICAL   DISEASES   OF   THE   EXTREMITIES 

bone  formation  is  very  extensive,  it  should  raise  the  suspicion  of 
syphihs. 

A  harmless  chronic  inflammation  of  the  olecranon  bursa,  corre- 
sponding to  the  same  condition  of  the  pre-patellar  bursa,  must  not 
be  confused  with  a  localized  tuberculosis  of  the  olecranon  (fig.  301). 

Occasionally  one  comes  across  persons  who  complain  so  per- 
sistently of  pain  in  the  region  of  the  internal  epicondyle,  that  one  is 
inclined  to  think  of  tubercle.  Sometimes  a  history  of  slight  injury 
is  given,  but  more  often  not.  Nothing  is  to  be  detected,  either  by 
ph3^sical  examination  or  by  a  skiagram.  These  cases  have  been 
termed  epicondylitis  (Francke)  and  the  symptom  has  been  attributed 
to  traumatism  of  the  insertion  of  the  ligament  and  of  the  peri- 
osteum ;  and  to  slight  inflammatory  changes,  e.g.,  after  influenza  or 
rheumatism. 


CHAPTER    LXXXV. 

TUMOURS    AND   ALLIED    SWELLINGS    ON    THE 
UPPER    ARM  AND    FOREARM. 

We  encounter  the  same  tumours  and  swellings  in  the  upper 
extremity  as  we  shall  come  across  in  discussing  the  lower  limb, 
especially  the  thigh;  but  they  are  rarer  in  the  arm. 

There  is  nothing  characteristic  about  the  tumours  of  the  skin 
and  the  subcutaneous  tissue  of  the  upper  limb.  Only  lipoma  of  the 
shoulder  (fig.  302)  and  the  pendulous  lipoma  of  the  axilla  (fig.  303) 
merit  special  mention. 

Spindle-shaped  tumours,  following  the  course  of  a  nerve,  and 
originating  in  the  deeper  soft  tissues,  are  usually  neuromata  or  neuro- 
fibromata,  but  may  be  sarcomata.  If  the  tumour  becomes  fixed 
on  muscular  contraction,  we  may  assume  that  it  has  an  iniraninscular 
origin,  in  which  connection  we  should  think  of  an  angioma  of  the 
muscle,  of  a  sarcoma,  of  a  gumma  or  of  tubercle. 

If  the  swelling  can  be  emptied  on  pressure,  or  by  elevating  the 
arm,  and  fills  up  again  when  the  arm  is  dependent,  it  is  suggestive  of 
an  angioma  of  the  muscle.  These  signs,  however,  only  apply  if 
the  angioma  is  definitely  of  the  cavernous  type.  But  most  of  these 
tumours  contain  a  large  amount  of  connective  tissue  and  of  fat,  and 
smooth  muscular  fibres  proliferate  therein,  so  that  they  feel  firm  and 
even  hard.     The  cavernous  type  is  badly  defined  and  extends  in  a 


TUMOURS   AND    ALLIED    SWELLIXGS 


573 


diffuse  manner  ;  but  the  hard  variety  is  definitely  circumscribed  and 
could  easily  be  taken  for  sarcoma  or  early  tubercle,  if  it  were  not 
for  two  contra-indicating  circumstances — the  long  duration  of  the 
disease,  and  the  attacks  of  acute  swelling  (thrombosis)  which  the 
patients  frequently  describe. 

Tubercle  of  the  muscle  appears  first  as  a  small  oval  swelling 
which  is  definitely  painful  on  pressure.  As  long  as  no  suppurative 
softening  and  abscess  formation  bursting  through  the  muscle  occur, 
the  diagnosis  can  only  be  one  of  probability,  supported  by  a  previous 
history  of  tubercle.  If  an  abscess  has  formed,  it  is  easier  to  recognize 
the  nature  of  the 
disease  ;  but  never- 
theless it  may  be 
impossible    in    some 


Fig.  302. — Lipoma  of  the  upper 
arm. 


Fig.  303. — Pendulous  lipoma  of  the  axilla. 


circumstances    to    exclude    primary  disease  of   the  bone  before  the 
operation  and  without  a  skiagram. 

A  young  man  showed  me  a  swelling,  which  had  arisen  a  few 
weeks  previously,  on  the  anterior  surface  of  the  left  forearm,  in  a 
position  where  there  were  no  glands.  Examination  showed  that  the 
swelling  was  either  intermuscular  or  intramuscular  ;  family  history 
revealed  tubercle  in  a  brother.  Diagnosis  :  tubercle  of  muscle. 
The  operation  showed  that  the  major  portion  of  the  palmaris  longus 


574 


SURGICAL   DISEASES   OF   THE    EXTREMITIES 


had  been  converted  into  a  tubercular  area,  which  had  not  yet  sup- 
purated. 

If  the  tumour  appears  to  be  neither  an  angioma  nor  a  tubercle, 
the  question  of  gumma  and  of  sarcoma,  which  are  rare,  will  arise. 

If  we  find  a  tumour  over  the  biceps,  resembling  a  pad  transversely 
to  the  muscle,  appearing  when  the  muscle  contracts  and  vanishing 
when  it  relaxes  (fig.  304),  it  can  only  be  a  hernia  of  muscle,  i.e.,  a 
firmly  contracted  mass  of  muscle  projecting  through  a  space  in  the 
aponeurosis. 

This  defect  mav  be  of  trau-       '  ' 


1 

i 

If 

i 

Fig.  304. — Hernia  of  biceps  muscle. 


Fig.  305. — Intramuscular  osteoma  after  a  contusioi 
a,  Connected  with  the  periosteum,  b.  Lying  free  i 
the  muscle. 


matic  origin  ;  but  it  is  occasionally  bilateral  and  is  probably  then 
a  congenital  peculiarity.  This  was  the  case  in  the  subject  depicted 
in  fig.  304,  in  whom  the  change  was  equally  pronounced  on  both  sides. 
If  a  tumour  of  bony  hardness  has  developed  after  an  injury — 
contusion  of  muscle,  laceration  of  muscle  after  dislocation — we 
may  assume  the  case  to  be  one  of  traumatic  osteoma,  a  circum- 
scribed ossifying  myositis.  This  is  a  process  intermediate  between 
new  growth  and  inflammation,  and  occurs  mostly  in  the  brachialis 
intei'nus  muscle  (fig.  305). 


TUMOURS   AND   ALLIED   SWELLIXGS 


575 


Fig.  306. — Gummatous  periostitis  and  ostitis  of  the  humerus 
and  end  of  the  ulna. 


Fig.  307.  —  Chronic  localized 
osteomyelitis  of  the  humerus 
(abscess  of  bone  and  sequestrum). 


Fig.  308. — Old  diffuse  osteomyelitis   of 
humerus. 


Fig.  309. — Myelogenous  tubercle  of  lower 
end  of  the  humerus  and  of  the  ulna  (in  a 
child).     Club-shaped  deformity  of  bone. 


57^  SURGICAL    DISEASES   OF   THE    EXTREMITIES 

If  a  tumour  is  connected  with  the  bone,  and  is  increasing  some- 
what rapidly,  it  is  necessary  to  differentiate  between  tubercle,  gumma, 
osteomyelitis  and  sarcoma  ;  if  the  growth  is  slow,  the  diagnosis 
will  lie  between  sarcoma,  fibroma,  and  chondroma. 

We  should  especially  think  of  tubercle  of  the  dinpliysis  in  children. 
This  condition  can  easily  be  mislaken  for  a  chronic  osteomyelitis, 
unless  the  pus  is  examined  bacteriologically,  both  in  its  perioste^d 
and  m37elogenous  forms. 

Aguninia  is  diagnosed  by  the  history  of  its  comparatively  painless 
course  and  by  a  skiagram. 

I  once  saw  a  gummatous  swelling  which  had  existed  for  two  years, 
and  which  I  definitely  looked  upon  as  a  sarcoma  before  ascertaining 
the  history  and  having  a  skiagram  taken.  The  patient,  however,  told 
me  that  he  had  had  syphilis  fifteen  years  before,  and  he  himself 
attributed  the  swelling  to  this  cause.  He  was  right  ;  the  skiagram 
confirmed  his  diagnosis  (fig.  306),  and  the  swelling  vanished  after 
specific  treatment. 

A  sarcoma  is  usually  first  recognized  when  its  circumference 
shows  that  it  cannot  be  either  tubercle  or  gumma.  If  the,  patient 
consults  the  doctor  soon  enough,  it  is  quite  possible  that  a  skiagram 
would  enable  an  early  diagnosis  to  be  made. 

Distension  of  the  bone,  if  very  circumscribed,  points  to  tubercle, 
but  may  also  indicate  sarcoma.  Periosteal  deposits  in  children 
occur  in  tubercle  and  in  comparatively  recent  osteomyelitis ;  •  in 
adults  almost  exclusively  in  the  latter  condition  and  in  gummata. 
Diffuse,  smooth  induration  (fig.  308)  or  slight  spindle-shaped 
distension  points  to  old  osteomyelitis  which  has  run  its  course.  The 
distension  may  still  be  concealing  a  sequestrum  (fig.  307).  Irregular 
proliferation  of  the  periosteum  must  be  ascribed  to  a  gumma  (fig.  306). 
A  nebulous  transparency  of  the  bone  in  its  entire  thickness  with  the 
loss  of  details  of  its  structure  suggests  a  sarcoma. 


CHAPTER    LXXXVI. 
INJURIES    OF    THE    WRIST    AND    HAND. 

(1)   RADIUS   AND    ULNA. 

The  diagnosis  of  injuries  of  the  wrist  was  a  very  simple  matter 
before  the  time  of  X-rays.  Anything  which  was  not  a  fracture  of  the 
radius  was  a  sprain,  and  vice  versa.  Dislocation  of  the  wrist  was 
looked  upon  as  a  curiosity,  and  it  was  asserted  that  the  injury  was 
so  rare  that  it  could  not  be  diagnosed.  The  X-rays  have  shed  some 
light  upon  this  comfortable   simplicity,  but   at  the  same  time  have 


INJURIES    OF   THE   WRIST   AXD   HAND 


577 


raised  new  problems  of  diagnosis.  In  addition  to  fracture  of  the 
radius  there  are  also  numerous  injuries  and  displacement  of  the 
carpal  bones  and  their  combinations.  If  these  could  only  be 
recognized  by  X-rays,  the  matter  would  be  no  more  difficult  in 
practice  than  heretofore.  Cases  previously  diagnosed  as  sprains 
would  now  be  sent  straightway  to  the  radiographer  as  "injuries  to 
the  wrist,"  and  nobody  would  take  the  trouble  to  attempt  to  diagnose 
a  fracture  of  the  radius.  But  fortunately  these  injuries  can  be 
diagnosed  without  X-rays  if  they  are  properly  examined. 

Fracture  of  the  radius  with  pronounced  fork-like  posterior 
displacement  need  not  detain  us.  It  cannot  be  mistaken  for  any- 
thing else,  if  the  classical  symptoms  are  present,  viz.,  displacement 
of  the  antei-ior  fragment  with   the   hand  posteriorly  and  towards  the 

radial  side,  freedom  of  the  wrist-joint  (fig.  311) 
and  deviation  of  the  styloid  process  of  the 
radius  with  the  wrist  away  from  the  axis  of 
the  radius  (fig.   312). 


Fig.  310. — Sub-periosteal  green- 
stick  fracture. 


Fig.  311. — Fork-like  posterior  displacement,  withfraclure  of  radius 
(case  of  detachment  of  epiphysis  with  great  displacement). 


The  styloid  process  of  the  ulna  is  usually  broken  off  in  distal 
fractures  (fig.  314,  &c.),  and  the  entire  lower  end  of  the  ulna  in  more 
proximal  fractures  (fig.  319).  This  latter  variety  usually  occurs  in 
children  and  in  old  people  with  weak  bones.  Further  back,  there 
occurs  the  greenstick  fracture  which  is  so  common  among  children 

(fig-  310)- 

If  the  fracture  involves  the  joint,  and  the  displacement  is  not  very 
pronounced,  the  diagnosis  is  more  difficult,  for  we  have  to  take  into 
consideration  both  sprains  and  injuries  to  the  carpus. 

If  the  movements  of  the  wrist-joint  are  free  and  painless,  there  can 
be  no  damage  therein,  so  that  if  there  be  an  injury  at  all  it  must 
involve  the  radius  at  some  distance  from  the  joint.     If  the  movements 


578 


SURGICAL    DISEASES   OF   THE    EXTREAIITIES 


are  painful  or  cannot  be  carried  out,  it  is  obvious  that  the  joint  is 
affected.  If,  after  fixing  the  joint  so  as  to  prevent  any  movement 
therein,  pressure  in  the  axis  of  the  forearm  causes  no  pain,  we  may 
exclude  a  recent  transverse  fracture  oi  the  radius.  But,  on  the  other 
hand,  if  it  does  cause  pain,  we  may  only  attribute  it  to  a  fracture  if 
it  is  distinctly  localized  on  the  elbow  side  of  the  wrist-joint. 

After  this  preliminary  examination,  we  proceed  to  a  more  accurate 
palpation.     If  the  styloid  process  of  the  radius  or  ulna  is  very  painful 

on  pressure,  and  if  it  is  also 
somewhat  thickened,  we  may 
conclude  that  there  is  a  frac- 
ture, even  if  it  is  not  possible 
to  feel  a  movable  fragment 
distinctly. 

We  then  feel  the  radius 
carefully  from  before  back- 
wards, and  as  a  control  from 
behind  forwards,  ascertain- 
ing, point  by  point,  the 
amount  of  pain  on  pressure. 
If  there  is  no  very  pro- 
nounced pain,  it  is  certain 
that  there  is  no  fracture.  But 
if  there  is  a  position,  on  the 
elbow  side  of  the  end  of  the 
radius,  wherein  a  definite 
and  circumscribed  pain  on 
pressure  exists,  we  must  as- 
sume that  there  is  a  fracture 
of  the  radius,  even  if  there 
be  no  visible  displacement, 
which  may,  of  course,  be 
concealed  by  the  general 
swelling.  If  this  circum- 
scribed pain  on  pressure  can 
be  traced  over  the  whole 
width  of  the  radius,  the  case  is  an  ordinary  transverse  extra-articular 
fracture  (figs.  315  to  318)  ;  but  if  the  pain  is  only  pronounced  at  the 
outer  side  and  if,  at  the  same  time,  there  is  some  effusion  into  the  joint, 
the  case  is  one  of  an  oblique  fracture  involving  the  joint  (fig.  321).  This 
variety  of  fracture,  described  by  Baiton  some  seventy  years  ago,  w^as 
at  that  time  the  subject  of  considerable  controversy.  We  now  know, 
thanks  to  the  X-rays,  that  this  fracture  is  not  at  all  rare. 

The  presence  of  articular  effusion,  or  at  least  of  hampered  activity 


*& 


.1 


fjQ_   212. — Deviation  of  hand  from  the  radius  in 
a  case  of  fractured  radius. 


INJURIES    OF   THE    WRIST   AND    HAXD  579 

of  the  joint,  in  association  with  more  or  less  pain  on  pressure  in 
a  transverse  direction,  should  raise  the  suspicion  of  a  combined 
fracture,  the  ordinary  varieties  of  which  are  illustrated  in  figs.  322 
and  323.  These  fractures  also  occur  more  frequently  than  was 
previously  thought. 

On  the  other  hand,  an  isolated  fracture  of  that  portion  of  the  end 
of  the  radius  which  is  turned  towards  the  ulna  is  very  much  rarer. 
Such  a  fracture  may  be  suspected  when  there  is  a  locahzed  pain  on 
pressure  between  the  radius  and  ulna,  and  when  the  movement  of 
rotation  is  painful. 

A  separation  of  the  epiphysis  must  be  thought  of  if  the  fracture  is 
situated  in  the  vicinity  of  the  epiphyseal  line  in  a  young  person. 
These  injuries  are  often  accompanied  by  damage  to  the  bone  itself, 
in  that  the  line  of  the  transverse  fracture  only  corresponds  partially 
to  the  cartilaginous  end,  or  by  the  existence  of  a  longitudinal  fissure 
in  the  bone — which,  however,  is  rare  (fig.  313). 

We  must  refer  to  another  variety  of  fracture,  which  occurs  mostly 
among  young  people.  This  is  illustrated  in  figs.  317  and  318,  wherein 
the  fracture  is  caused  by  sudden  axial  pressure,  for  instance,  a  fall 
on  the  palm  of  the  hand.  In  this  case  there  is  neither  false  ixiobility 
nor  displacement.  The  loss  of  power  is  often  so  slight  that  no 
fracture  is  suspected.  But  careful  examination  will  show  that  there 
is  a  sharply  defined  transverse  area  of  pain  on  pressure,  above 
the  edge  of  the  radius  over  the  whole  extent  of  the  metaphysis. 
The  skiagram  reveals  on  either  side  a  slight  roof-like  projection 
of  the  bone,  showing  that  the  radius  has  been  compressed  and 
that  the  crushed  bone  has  been  pushed  out  laterally  because  of  the 
msufficient  strength  of  the  bone  in  its  long  axis. 

If  it  is  certain  that  a  fracture  of  the  radius  is  present,  we  must 
examine  for  the  injuries  which  so  often  accompany  this  accident, 
namely,  detachment  of  the  styloid  process  of  the  ulna  and  fracture  of 
the  scaphoid  (see  below). 

(2)  WRIST-JOINT. 

If  nothing  is  found  in  the  radius,  we  must  consider  whether  the 
carpal  bones  have  sustained  any  injury,  or  whether  the  case  is  one 
of  a  simple  sprain.  The  typical  examples  of  the  former  consist  of 
palmar  dislocation  of  the  semilunar  bone,  fracture  of  the  scaphoid, 
and  a  combination  of  the  two. 

(a)  If  we  find,  under  the  flexor  tendons,  a  bony  protuberance 
projecting  towards  the  palm,  or  even  only  a  marked  thickening  of  the 
skeleton  of  the  wrist  in  an  antero-posterior  plane,  in  a  case  wherein 
the  joint  is  very  painful  and  has  lost  its  power,  we  must  assume  that 
there  is  probably  a  palmar  dislocation  of  the  semilunar  bone.  This 
diagnosis  would  be  confirmed  by  the  subsequent  onset  of  neuralgia 
in  the  terminal  fibres  of  the  median  nerve. 

These  injuries  are  nearly  always  recognizable  in   skiagrams  taken 


58o 


SURGICAL   DISEASES   OF   THE   EXTREMITIES 


Fig.  313. — Commencing  separation  of  the  epi- 
physis of  radius,  wilh  a  longitudinal  fissure. 


Fig.  314. — Transverse  fracture  of  radius,  with 
detachment  of  styloid  process  of  ulna. 


Fig.  315. — Separation  of  epiphysis  of  radius, 
with  displacement  of  radius  backwards.  Patient 
aged  19.     (Case  of  fig.  311.) 


Fig.  316. — Same  case,  from  the  side. 


INJURIES    OF   THE    WRIST   AND    HAND 


581 


Fig.  317- — Fracture  of  radius,  caused  by 
axial  pressure,  in  a  boy  aged  10. 


Fig.  318.  —  Same  case,  from  the  side. 


Fig.  319. — Fracture  of  radius  far  back,  with 
detachment  and  partial  shattering  of  lower  end 
of  ulna. 


Fig.  320. — Same  case,  from  the  side. 


582 


SURGICAL   DISEASES   OF   THE   EXTREMITIES 


Fig.  321. — Oblique  fracture  of  lower  end  of 
radius. 


Fig.    322.— Combined  fracture  of  radius. 
(Oblique  fracture  on  the  radial  and  ulnar  side.) 


Fig.  323.  —  Combined  fracture  of  radius. 
(Transverse  fracture,  with  oblique  fracture  on 
the  ulnar  side.) 


Fig.  324.  —  Dorsal  deviation  of  the  distal  frag- 
ment in  a  case  of  fractured  radius.  (An  old 
case,  in  which  line  of  fracture  is  still  clearly 
recognizable.) 


INJURIES   OF   THE   WKIST   AND    HAND 


583 


Fig.  325. — Normal  wrist-joint. 


Fig.  326.  —Palmar  dislocation  of  the  semilunar  bone. 


Fig.  327. — Normal  wrist.     C  =  Os  magnum. 
N  =  Scaphoid.     L  =  Semilunar. 


Fig.  328.— Palmar  dislocation  of  the  semilunar. 
References  as  in  previous  figure. 


5S4 


SURGICAL  diseasp:s  of  the  extremities 


in  the  dorso-palmar  position.  The  semilunar  is  somewhat  obHquely 
directed  towards  the  scaphoid,  and  its  distal  articular  surface  look- 
ing towards  the  radius  is  easily  detected  (c/.  figs.  325,  326).  A 
skiagram  taken  in  the  lateral  position  always  exiiibits  these  injuries 
very  clearly,  and  this  measure  should  never  be  neglected  in  any 
obscure  injury  of  the  carpus.  Such  a  skiagram  shows  the  semilunar 
bone  deviated  towards  the  palm,  with  the  head  of  the  os  magnum 
lying  upon  its  dorsal  surface  {cf.  figs.  327  an  d  328).  In  these 
cases  the  os  magnum  might  be  looked  upon  as  dislocated  just  as 
well  as  the  semilunar. 

{h)  If  in  addition  to  a  moderate  amount  of  palmar  projection,  there 
is  definite  pain  on  pressure  over  the  scaphoid  with  shortening  of  the 
carpal    region,  and    probably  also   some    radial    displacement  of  the 

hand,    we     must     assume 
!  :      '^       f'^M  i       ^^^^^    ^^^     wrist    has    sus- 

"^  tained  a  combined  injury. 
This  combined  injury 
usually  consists,  as  I  have 
shown,  of  fracture  of  the 
scaphoid  with  palmar  dis- 
location of  the  semilunar 
and  the  proximal  fragment 
of  the  scaphoid  attached 
to  it.  We  term  this  for 
convenience  the  typical 
intercarpal  dislocation 
fracture. 

Fig.  330  is  taken  from 
the  case,  in  which  both 
sides  were  affected,  which 
first  suggested  to  me  the 
typical  character  of  this 
injury.  Sometimes  there 
is  a  transverse  fracture  of 
the  os  magnum  combined  with  tlie  injury  ;  the  styloid  process  of  the 
radius  or  of  the  ulna  may  also  be  broken  off  occasionally.  A  definite 
fracture  of  the  radius  may  even  be  present. 

(c)  If  there  be  no  abnormal  bulging  we  must  dift'erentiate  mainly 
between  a  simple  fracture  of  the  scaphoid  and  a  pure  sprain— apart 
from  anything^exceptional.  If  both  fragments  of  the  broken  scaphoid 
retain  their  normal  position,  as  is  often  the  case,  the  only  sign  of 
fracture  of  the  scaphoid  may  be  a  narrowly  circumscribed  and  per- 
sistent pain  on  pressure  over  the  broken  bone,  i.e.,  in  an  area  distal 
and  internal  to  the  easily  felt  styloid  process  of  the  radius.  This  pain 
on  pressure  sometimes  permits  us  to  suspect  this  fracture  long  after 
the  infliction    of  the    injury.      The    diagnosis    is    easier 


Fig.  329. 


-Transverse  fracture  of  the  scaphoid  without 
displacement. 


when    the 


INJURIES    OF   THE    WRIST   AND    HAND 


585 


proximal  fragment  is  displaced  towards  the  palm,  because  a  careful 
comparison  of  the  two  hands  would  probably  show  that  there  was 
a  projection  towards  the  palm  on  one  radial  side. 

A  skiagram  usually  demonstrates  a  fracture  of  the  scaphoid  at 
the  first  glance  (fig.  .329).  Doubt  can  only  arise  if  the  scaphoid  is 
placed  steeply,  so  that  its  distal  portion  overlays  its  proximal  portion. 
The  skiagram  is  then  liable  to  erroneous  interpretation,  as  occurred 
so  often  when  X-ray  diagnosis  was  in  its  infancy.  When  the  scaphoid 
is  in  such  a  position  it  is  not  possible  to  recognize  fracture  thereof  at 
the  first  glance  (see,  e.g.,  the  scaphoid  in  fig.  323).  A  control  skiagram 
must  therefore  be  taken  with  the  wrist  slightly  flexed  and  adducted 
towards  the  ulna. 

If  there  is  no 
local  pain  on  pres- 
sure over  the  scap- 
hoid, we  are  justified 
in  limiting  the  clin- 
ical diagnosis  to  that 
of  a  sprain.  But  if 
pain  persists  after 
an  injury  which  has 
been  assumed  to  be 
a  wrench,  or  if  any 
doubt  exists  from 
the  first,  we  must 
resort  to  an  X-ray 
examination.  This 
will  probably  show 
that  we  have  missed 
some  injury  which 
is  not  palpable,  e.g., 
a  contused  fracture 
of    the     semilunar 

bone  which  can  hardly  be  detected  without  an  X-ray  examination, 
and  which  may  lead  to  atrophy  or  to  the  partial  formation  of  a 
sequestrum.  I  have  seen  such  an  injury  occur  as  a  result  of  an 
indirect  trauma. 

It  is  most  important  to  make  an  X-ray  examination  in  all  injuries 
resulting  from  accidents,  which  we  may  be  inclined,  perhaps  unjustifi- 
ably, to  attribute  to  malingering  and  exaggeration.  If  the  skiagram 
fails  to  reveal  anything,  we  may  then  definitely  speak  of  a  sprain,  and 
make  our  prognosis  accordingly. 

We  have  hitherto  confined  ourselves  to  injuries  which  frequently 
occur  in  practice,  and  the  diagnosis  of  which  is  important  for  the 
general  practitioner.  But  there  are,  in  addition,  rare  dislocations  in 
the  radiocarpal  joint,   in  the  intercarpal  joints  and  carpo-metacarpal 


Fig.  330. — Typical  intercarpal  dislocation-fracture.  (Frac- 
ture of  the  scaphoid,  with  palmar  dislocaiion  of  the  semilunar, 
L,  and  of  the  proximal  fragmtnt  of  the  scaphoid,  N2-) 


586 


SURGICAL   DISEASES    OF   THE    EXTREMITIES 


joints,  some  of  which  can  be  diagnosed  by  careful  palpation,  taking 
into  consideration  the  position  of  the  styloid  processes,  but  which  can 
all  be  definitely  diagnosed  by  means  of  X-rays. 


(3)  THE  METACARPUS  AND   FINGERS. 

Fracture  of  the  metacarpals  can  easily  be  distinguished  from 
simple  contusions  bv  traction  and  pressure  on  the  corresponding 
fingers.  Only  a  longitudinal  fracture  would  remain  painless  on  such 
manipulation. 

Fracture  of  the  base  of  the  first  metacarpal  may  be  mentioned  as 
a  typical,  though  not  as  a  frequent  injury.     It  is   usually  regarded  as 

a  sprained  thumb,  but  the 
persistent  pain  shows  that 
some  more  severe  injury  is 
present. 

The      skiagram      shows 


Fig.  331. — Contusion  fracture  of  semilunar  X  (trau- 
matic softening). 


Fig.  332.-  -Fracture  of  the 
base  of  first  metacarpal. 


either  a  transverse  fracture  of  the  upper  end  of  the  base  (fig.  332),  or 
a  piece  of  bone  broken  off  its  palmar  surface  (Bennett's  fracture). 

The  circulatory  disturbances  which  follow  injuries  of  the  bones 
and  soft  parts  are  "^most  pronounced  on  the  back  of  the  hand,  just  as 
in  the  case  of  inflammation.  They  are  liable  to  persist  in  this 
position  for  a  considerable  time,  even  if  they  are  not  kept  up  by  the 
manipulation  of  the  patient  who  is  insured  against  accidents.  This 
condition  has  been  termed  "  hard  traumatic  cedema  of  the  back  of 
the  hand  "  (Secretan),  but  it  has  also  been  shown  to  be  the  result 
of  percussion,  practised  by  those  who  shirk  work  while  seeking 
compensation. 


INJURIES   OF   THE   WRIST   AXD    HAND 


587 


Fractures  and  dislocations  of  the  fingers  are  so  easy  to  recognize 
that  they  need  not  detain  us.  The  same  apphes  to  dislocation  of  the 
thumb,  so  well  known,  because  of  the  difficulty  of  its  reduction.  It 
is  an  injury  which  cannot  be  mistaken  for  anything  else. 

The  following  scheme  summarizes  the  foregoing  remarks  on 
injuries  of  the  wrist  : — 


No  deformity  of  bone, 
evident  on  inspec- 
tion or  palpation. 


'  Radius  nowhere  showing 
any  localized  pain  on 
pressure  ;  carpus  usually 
somewhat  swollen  ;  loss" 
of  power  always  pro- 
nounced ;  Rbntgen  rays 
always  required.  , 


Radius  painful  on  localized 
pressure,  behiyid  the  line' 
of  the  wrist-ioint. 


Pain  on  pressure  diffuse. 

Localized  pain  on  pressure 
in  the  tabatiere. 

Localized  pain  on  pres- 
sure over  the  semilunar 
(middle  of  the  back  of 
carpus). 

Wrist  free ;  the  pain  on 
pressure  runs  in  a  trans- 
verse direction. 

Wrist  swollen ;  loss  of 
power  ;  pain  on  pressure 
close   to  dorsal   edge    of 

'     radius. 


(ij  Sprain  of  hand. 

(2)  Fracture  of  scaphoid. 


(3)  Contused  fracture  of 
the  semilunar. 


(4)  Extra-articular  trans- 

verse     fracture     of 
the  radius, 

(5)  Fracture  of  radius  ex- 

tending into  joint. 


Definite   deformitj'   cf 
wrist. 


Shape  of  wrist  like  the  back 
of  a  fork,  with  the  bend 
more  towards  the  elbow. 


,  Joint  free. 


Shape  of  wrist  like  the  back 
of  a  fork,  with  the  bend-{ 
near  the  carpus. 


(6)  Extra-articular  fracture 

of  radius,  3-4  cm.  or 
more  behind  the  joint ; 
usually  with  detach- 
ment of  lower  end  of 
ulna. 

(7)  Extra-articular  fracture 
of  radius  near  joint  : 
often  with  fracture  of 
stj-loid  process  of  ulna 
(also  separation  of  epi- 
physis). 

(3)  Intra-articular  fracture 
of  radius  (oblique  frac- 
ture or  transverse  and 
oblique  fracture). 

,  Xo   definite    shortening   of  (9)  Dislocation       of     the 

hand  ;    localized    promin-  semilunar. 
I      ence   of  bone   under   the 
Dorso-palmar  thickening  of  !      fle.xor  tendons, 
the  joint  without  definite-? 

fork  shape  of  wrist.              !  Shortening  of  hand  ;   large  (10)  Inter-carpal     disloca- 

■      mass   of  bone  imder   the  tion  -  fracture     (frac- 

I      flexor   tendons;    pain   on  ture    of   scaphoid    and 

^     pressure  over  tabatiere.  dislocation      of     semi- 
lunar) ;  not  rare. 


Joint    swollen,   tender   and 
stiff. 


38 


-588  SURGICAL   DISEASES   OF   THE    EXTREMITIES 

CHAPTER   LXXXVII. 
INFLAMMATORY  PROCESSES   ABOUT   THE  WRIST. 

(1)  ACUTE    INFLAMMATIONS. 

We  need  only  briefly  refer  to  the  severe  inflammatory  oedeixia  of 
the  back  of  the  hand,  which  may  follow  any  infected  wound  of  the 
skin,  either  on  the  palm  or  on  the  dorsum.  We  must,  however,  deal 
in  more  detail  with  inflammations  of  the  tendon-sheaths,  wherein 
there  may  be  some  doubt  at  first  as  to  the  primary  seat  of  the  in- 
flammation. If  the  patient  states  that  the  swelling  has  followed  a 
perforated  wound  of  the  finger,  or  a  bite,  &c.,  we  should  at  once 
think  of  the  tendon  sheaths,  because  such  insignificant  peripheral 
wounds  frequently  lead  to  acute  suppuration  within  them. 

The  character  of  the  loss  of  power  furnishes  an  important  differen- 
tiating sign.  Inflammation  of  the  tendon  sheath  especially  interferes 
with  the  movements  of  ilie  fingers,  whereas  disease  of  the  joint  affects 
the  movements  of  the  wrist.  An  inflamed  wrist  is  painful  all  over, 
whereas  in  inflammation  of  the  tendon  sheaths  the  aft'ected  side  only 
is  painful.  In  acute  arthritis,  traction  and  pressure  in  the  axis  of  the 
wrist  is  painful,  but  this  is  not  the  case  when  the  tendon  sheaths 
are  inflamed.  Finally,  teno-synovitis  always  spreads  in  a  longitudinal 
direction,  whereas  arthritis  remains  limited  to  the  neighbourhood  of 
the  joint. 

It  sometimes  happens  that  the  joint  becomes  secondarily  involved 
after  a  primary  inflammation  of  the  tendon  sheaths.  We  may  assume 
that  such  an  event  has  occurred  if  pain,  oedema  and  pyrexia  persist, 
despite  the  opening  of  all  superficial  areas  of  pus,  or  if  we  feel  and 
hear  a  sound  of  grating  on  moving  the  joint.  This  latter  sign 
indicates  that  the  articular  cartilage  has  been  partially  separated  or 
destroyed  by  the  inflammation.  On  the  other  hand,  the  tendon 
■sheaths  may  become  secondarily  involved  as  a  result  of  disease  in 
the  joint  or  in  the  bones. 

If  the  teno-synovitis  has  extended  to  the  forearm,  and  is  accom- 
panied by  fever,  oedema  and  pain,  we  must  carefull}'-  search  for 
suppuration  in  order  to  make  a  timely  incision  into  the  abscess. 
As  this  is  often  situated  deeply  on  the  interosseous  ligament,  we  must 
not  wait  for  fluctuation  before  making  a  diagnosis. 

Having  diagnosed  an  inflammation  of  the  joint,  we  must  next 
determine  its  natnre  and  its  canse. 

If  other  joints  are  also  affected,  and  the  inflammation  subsides 
after  the  administration  of  salicylates,  we  may  assume  that  the  case 
is  one  of  acute  articular  rheumatism.  If  only  one  joint  is  aft'ected, 
and  -the  salicylates  are  ineftective,   gonorrhoea  is  the  most  probable 


INFLAMMATORY    PKOCESSES    ABOUT   THE    WRIST  589 

•cause,  even  if  an  injury  is  invoked  as  a  pretext,  or  has  aclually 
happened. 

An  hotel  servant  sought  to  claim  his  accident  compensation  because 
•of  an  acute  swelling  of  his  wrist,  having  sprained  it  in  lifting  a 
portmanteau.  When  asked  whether  he  had  had  gonorrhoea,  he  at 
once  gave  the  desired  reply.  The  lifting  of  the  portmanteau  was 
merely  the  occasion  of  the  first  appearance  of  symptoms  of  inflam- 
mation ;  although,  of  course,  the  sprain  may  have  favoured  the 
attack  of  the  gonococci  on  the  joint.  The  patient  should  produce 
the  most  irrefutable  evidence  of  an  accident  before  an  injury  can 
be  made  responsible,  even  in  a  limited  manner,  for  such  an 
arthritis. 

For  the  rest  we  may  refer  to  what  has  already  been  said  in 
connection  with  the  shoulder-joint.  In  a  few  cases  the  diagnosis 
must  be  made  by  the  course  of  the  disease.  Acute  articular  rheu- 
matism runs  a  rapid  course  and  does  not  usually  impair  the  power 
of  the  joint  ;  gonorrhoea  takes  a  long  time  to  recover,  often  lasting 
for  months.  In  some  cases  it  leaves  the  joint  free,  in  others  stiff. 
Staphylococci  and  streptococcic  infection  lead,  as  a  rule,  to  suppuration 
and  to  partial  stiffening. 

(2)  CHRONIC    INFLAMMATORY    PROCESSES. 

No  difficulty  usually  attends  the  diagnosis  of  inflammation  of  the 
wrist,  which  is  chronic  from  the  start.  If  several  joints  have  been 
affected  symmetrically,  the  case  is  one  of  chronic  articular  rheu- 
matism, the  varieties  and  causes  of  which  have  already  been  dis- 
cussed in  connection  with  inflammations  of  the  shoulder-joint. 

If,  on  the  other  hand,  only  one  wrist  is  affected,  there  is  no  alterna- 
tive but  to  assume  that  the  case  is  one  of  tubercle  (fig.  334).  It  is 
most  important  to  recognize  this  condition  in  its  early  stages. 
If  the  extent  of  the  movements  at  the  wrist  gradually  becomes 
restricted,  if  those  which  are  executed  are  painful,  if  there  is  also 
slight  pain  on  pressure,  and  some  muscular  atrophy  supervenes  in 
the  forearm,  we  should  think  of  tubercle,  even  though  there  be  no 
visible  swelling.  If  there  is  swelling,  the  question  as  to  its  differeiitia- 
tion  from  tubercular  teno-synovitis  may  arise.  The  clinical  pictures 
of  the  two  diseases  are,  however,  quite  different.  In  tubercle  of  the 
joint  the  whole  wrist  is  thickened  in  a  spindle-shaped  manner,  in 
advanced  cases  the  hand  is  in  a  position  of  slight  palmar  dislocation 
with  complete  extension  of  the  fingers  (fig.  334).  The  pain  on 
pressure  is  equally  pronounced  on  both  sides  of  the  joint,  and 
there  is  also  pain  on  traction  or  pressure  in  the  axis  of  the  wrist, 
as  well  as  on  any  attempt  at  active  or  passive  movements  of  the  joint. 
In  teno-synovitis,  however,  the  swelling  is  only  on  one  side,  generally 


590 


SURGICAL   DISEASES   OF   THE    EXTREMITIES 


Fig.  333. — Wrist  in  arthritis  deformans. 


Fig.  334. — Tubercle  of  the  wrist. 


Fig.   335. — Tubercular  leno-synovitis  of  the  flexor  tendons.     Fingers  slightly 
contracted  in  flexion. 


INP^LAMMATORV    PROCESSES    ABOUT   THE   WRIST 


591 


Fic.    336.  — Arthritis   deformans. 
(Skiagram  of  fig.  333.) 


Fig.  337. — Tubercular  arthritis. 


Fig.   338. — Acute   maculated    osteoporosis  in  a 
case  of  complicated  fracture  of  the  elbow. 


Fig.  339. — Rickety  changes  in 
bone. 


592  SURGICAL   DISEASES   OF   THE    EXTREMITIES 

on  the  palmar  surface,  and  its  maximum  degree  is  not  at  the  level 
of  the  wrist,  where  the  tendon  sheath  is  firmly  bound  down  by  the- 
strong  anterior  carpal  ligament,  but  either  proximally  or  distally 
thereto  (see  fig.  335).  The  fingers  are  not  extended,  but  are  slightly 
contracted  in  fiexion,  and  there  is  no  palmar  subluxation  of  the  hand. 
If  there  be  any  pain  on  pressure,  it  is  limited  to  the  aft'ected  surface.. 
The  movements  of  the  joint  are  only  mechanically  hindered  by  the 
swelling,  but  are  scarcely  painful.  Pressure  on  the  joint  causes  no 
pain. 

If  the  joint  is  stiff  and  the  movements  of  the  fingers  very  restricted, 
and  if  fistulas  are  present,  it  is  neither  necessary  to  inoculate  guinea- 
pigs  nor  to  take  a  skiagram  in  order  to  establish  the  diagnosis  of 
tubercular  arthritis. 

A  skiagram  gives  valuable  information  in  all  stages  of  the  disease 
concerning  the  site  and  extent  of  the  affection  of  the  bone,  and  of  the 
condition  of  the  articular  cartilage.  In  the  early  stage  of  synovial 
disease,  X-ray  examination  only  shows  a  diffuse  osteoporosis,  which 
differs  by  its  greater  uniformity  from  the  acute  maculated  osteo- 
porosis which  occurs  in  acute  inflammatory  processes  and  in  fractures 

(t^g-33S). 

If  the  disease  starts  in  the  bone,  it  can  be  recognized  very  early,. 
In  both  forms  the  cartilage  disappears  in  the  couise  of  the  disease, 
and  the  individual  bones  come  into  direct  contact.  In  the  later 
stages  the  bones  appear  merely  as  shapeless  and  nebulous  structures 

(fig-  337)- 

The  extreme  degree  of  bony  changes  which  may  exist  in  arthritis- 
deformans  is  shown  in  fig.  336.  It  is  interesting  to  compare  with  it  a. 
skiagram  of  a  case  of  rickets  (fig.  339). 


CHAPTER  LXXXVIII. 

ABNORMAL  POSITIONS  AND  POSTURES  OF 
THE  HAND  AND  FINGERS. 

^.—RESULTS  OF  INJURIES  TO  NERVES. 

We  have  already  referred  on  various  occasions  to  paralytic  con- 
ditions of  the  upper  limb,  which  are  of  surgical  importance.  But  it 
may  not  be  superfluous  to  briefly  summarize  what  has  already  beert 
said,  and  to  make  a  few  amplifications. 

Two  questions  arise  in  every  case  of  paralysis  : — 

(i)  Which  muscles  are  paralysed  ? 


ABXORMAL  POSITIOXS  AND  POSTURES  OF  THE  HAXD  AND  FINGERS    595 

(2)  Where  is  tlie  interruption  in  the  conducting  path  of  the  nerve  ? 

The  reply  to  the  first  question  only  demands  a  knowledge  of 
muscular  function  and  a  careful  examination.  Often  a  mere  glance 
at  the  patient  suffices  for  an  approximate  diagnosis,  when  the  limb  is 
held  m  a  characteristic  posture.  If  the  hand  hangs  prone  and  lax, 
and  the  fingers  cannot  be  extended,  it  is  obvious  that  the  case  is  one 
of  radial  nerve  paralysis.  If  the  thumb  is  extended  against  the  index 
finger  and  cannot  be  moved  away  from  this  position,  we  should  think 
of  paralysis  of  Hie  median  nerve,  and  should  test  the  power  of  abduc- 
tion and  flexion  of  the  index  and  middle  fingers  especially.  If  this, 
power  is  lost,  and  if  at  the  same  time  the  sensibility  of  the  dorsal 
surface  of  the  terminal  phalanges  is  abolished,  there  can  be  no  doubt 
about  the  diagnosis.  If,  on  the  other  hand,  the  thumb  cannot  be- 
actively  approximated  to  the  hidex  finger,  if  the  basal  phalanges  of  the 
second  and  fifth  fingers  are  slightly  over-extended  while  the  middle 
and  terminal  phalanges  are  slightly  flexed,  we  should  at  once  suspect 
paralysis  of  the  nlnar  nerve.  It  is  easier  to  diagnose  this  condition  at 
a  first  glance  in  the  later  stages,  when  the  thumb,  hypothenar 
eminence,  and  interossei  are  atrophied  and  the  fingers  have  assumed 
the  well-known  posture  of  "main  en  grift'e,"  i.e.,  over-extension  of 
the  basal  phalanges  with  severe  flexion  of  the  middle  and  terminal 
phalanges  (fig.  346). 

If  the  patient  cannot  actively  raise  his  arm  at  the  shoulder,  though 
the  movement  can  be  performed  passively  without  difficulty,  we 
should  thhik  of  paralysis  of  the  circumflex  nerve,  and  should  test 
whether  there  is  any  loss  of  sensation  in  the  area  to  which  the 
sensory  branches  of  the  nerve  are  distributed  (over  the  deltoid 
muscle). 

The  second  question,  relating  to  the  site  of  the  damage,  is,  however, 
of  greater  importance  from  the  point  of  view  of  surgical  treatment. 
This  is  frequently  quite  clear  from  the  original  cause  of  the  disturb- 
ance {e.g.,  aneurism,  tumour,  &c.),  or  from  the  position  of  an  injury, 
such  as  a  cut,  stab,  or  fracture  of  bone.  Cuts  over  the  wrist,  which 
frequently  involve  the  ulnar  or  even  the  median  nerve,  and  fractures 
of  the  humerus,  which  may  sacrifice  the  radial  nerve,  are  mainly 
responsible.  At  the  level  of  the  shoulder-joint  the  dislocated  head  of 
the  humerus  may  bruise  the  circumflex  nerve,  or,  more  rarely,  one  of 
the  lai-ge  cords  of  the  brachial  plexus.  In  the  supraclavicular  region 
the  plexus  may  be  directly  injured,  or  mdirectly,  by  means  of  a. 
fragment  of  a  broken  clavicle. 

In  the  absence  of  any  such  indication,  or  in  cases  wherem  the- 
injury  involves  simultaneously  several  sections  of  the  limb,  we  should 
always  give  the  preference  to  the  causation  which  is  able  to  attribute 
all  the  paralysis  to  one  individual  lesion.  An  example  wiU  make  this 
clear. 


594  SURGICAL   DISEASES    OF   THE   EXTREMITIES 

A  workman  was  hit  on  the  head  and  shoulder  by  a  large  block  of 
stone.  When  we  saw  him  a  few  weeks  subsequently,  we  were  particu- 
larly struck  by  the  posture  of  the  left  hand,  which  corresponded  to 
that  of  radial  paralysis.  A  fracture  of  the  upper  third  of  the  humerus, 
which  had  healed  somewhat  at  an  angle,  appeared  at  first  sight  to 
furnish  the  required  explanation.  But  further  examination  showed 
that  not  only  did  the  paralysis  concern  the  extensors  of  the  fingers 
and  wrist  and  the  supinators,  but  that  it  also  involved  the  deltoid 
muscle,  and  that  there  was  loss  of  sensation  over  the  area  supplied  by 
the  circumflex  nerve.  All  this  made  it  evident  that  the  circumflex 
nerve  was  damaged  when  the  fracture  of  the  upper  arm  occurred. 
But  this  did  not  explain  the  paralysis  and  atrophy  of  the  supra- 
spinatus  and  infraspinatus  muscles,  which  were  no  less  striking  than 
the  other  paralysis.  There  must,  therefore,  have  been  some  injury 
higher  up,  and,  as  a  matter  of  fact,  there  was  a  badly  united  fracture 
of  the  clavicle,  the  peripheral  end  of  whose  ceritral  fragment  exactly 
corresponded  with  the  position  of  Erb's  point. 

We  were  obviously  not  dealing  with  separate  paralvses  of  the 
radial,  circumflex  and  suprascapular  nerves,  but  with  a  contusion  of 
the  nerve  cord  composed  of  the  fifth  and  sixth  roots,  between  the 
clavicle  and  the  first  rib — the  so-called  Erb's  point.  The  accuracy  of 
this  assumption  was  proved  by  the  fact  that  the  muscles  whose  nerve 
supply  corresponded  exactly  with  the  fifth  and  sixth  roots  were  com- 
pletely paralysed,  i.e.,  the  supraspinatus,  infraspinatus,  deltoid, 
coraco  brachialis,  brachialis  anticus,  supinator  longus  and  brevis.  The 
nerve  fibres  to  the  long  extensors  of  fingers,  which  are  given  off  much 
lower  down,  were,  however,  evidently  less  directly  involved,  and  the 
corresponding  muscles  therefore  suffered  less  damage. 

Just  as  damage  to  the  upper  roots  of  the  brachial  plexus,  causing 
Erb's  paralysis,  produces  a  fairly  uniform  clinical  picture,  notwith- 
standing certain  irregularities,  a  similar  result  follows  from  damage  to 
the  lower  roots,  causing  Klumpke's  paralysis.  In  this  condition,  the 
paralysis  of  the  small  muscles  of  the  hand,  and  the  disturbed  sensation 
in  the  region  of  the  median  and  ulnar  nerve,  are  combined  with 
oculo-pupillary  derangements,  such  as  miosis,  narrowing  of  the 
palpebral  fissure  and  retraction  of  the  eveball.  The  more  protected 
position  of  the  lower  roots  usuallv  prevents  their  exposure  to  injury, 
and  therefore  Klumpke's  paralysis  is  more  frequently  encountered  as 
a  result  of  tumours  or  inflammatory  diseases  of  bone  {e.g.,  spinal 
caries). 

The  patient  has  not  always  paratysis  when  he  consults  the  surgeon. 
The  latter  often  has  more  occasion  to  see  paralyses  of  the  upper  ex- 
tremity arise  as  a  result  of  treatment.  These  include  aucvsthesia 
paralysis,  Esumrch's  paralysis  and  crutch  palsw 

The  first  condition  usually  represents  paralysis  of  the  circumflex 
or  radial  nerve,  and  depends  upon  compression  of  the  nerve-roots 
between  the  humerus  and  thorax,  or  between  the  humerus  and  the 
edge  of  the  operating  table,  when  the  arm  is  raised.     The  mechanism 


ABNORMAL  POSITIONS  AND  POSTURES  OF  THE  HAND  AND  FINGERS   595 

of  the  two  other  forms  of  paralysis  requires  no  further  explanation. 
In  all  the  three  forms  the  motor  fibres  are  usually  alone  affected, 
and  spontaneous  recovery  occurs  in  a  few  weeks,  or  at  latest  in  a  few 
months.  The  course  of  ischaemic  paralysis  which  comes  on  after 
too  tight  an  application  of  a  firm  bandage,  is  quite  different,  because 
in  such  a  case  there  is  direct  damage  to  the  muscle  in  consequence 
of  the  deficient  blood  supply.  The  final  result  is  not  one  of  recovery 
but  a  fibrous  degeneration  of  the  muscle  with  contracture,  in  other 
words  a  permanent  damage. 


Fig.  ^40. — Manus  vara.     Absence  of  radius 
and  of  thumb. 


Fig.  341. — Skiagram  of  same  case. 


^.—ABNORMAL    POSTURES    OF   THE    WRIST-JOINT. 

Abnormal  postures  of  the  hand  are  less  frequent  than  those  of 
the  foot.  Apart  from  ordinary  traumatic  deformities  we  distinguish 
congenital  manus  vara  and  acquired  manus  valga. 

Manus  vara,  clubbed  hand,  which  is  generally  seen  in  infants, 
always  indicates  a  partial  or  complete  defect  in  the  radius.  The 
thumb  is  often  absent  in  these  cases  (figs.  340  and  341). 


596 


SURGICAL   DISEASES    OF   THE    EXTREMITIES 


Fig.  342. — Manus  valga.     Madelung's  deformity  or  the  hand. 


Fig.  343. — Radio-ulnar  skiagram  of  the  same  case. 


Fig.  344. — Dorso-palmar  skiagram  of  the  same  case. 


ABNORMAL  POSITIONS  AXD  POSTURES  OF  THE  HAXD  AND  FINGERS    597 


M  a  n  u  s 
valga,  "  ^la- 

delung's  de- 
form i  t  \'  o  f 
the  hand," 
occurs,  not 
very  infre- 
quently, in 
females.  The 
hand  looks  as 
if  it  had  sus- 
tained a  pal- 
mar sublux- 
ation. The 
lower  end  of 
the  ulna  is 
entirely  dis- 
placed from 
its  normal 
connections 
and  projects 
m.arkedly  towards  the  dorsum. 
There  is  pain  for  a  certain 
period  of  the  disease,  just  as  in 
genu  valgum  and  pes  valgus,  and 
then  it  completely  disappears. 

The  cause  of  this  condition 
is  not  so  much  the  result  of 
occupation,  as  was  originally 
thought,  but  is  due  to  some 
change  in  the  bone,  depending 
upon  curvature  of  the  whole 
radius,  resulting  from  late 
rickets.  Its  distal  articular  sur- 
face inclines  towards  the  uhia 
and  towards  the  palm,  and  thus 
allows  the  whole  carpus  to  glide 
palmwards,  causing  a  subluxa- 
tion (figs.  343  and  344).  The 
diagnosis  is  made  at  first  sight. 

It  is  but  rarely  that  separa- 
tion of  the  epiphysis  due  to 
injury 


Fig.  345. — Bilateral  Dupuytren's  contraction. 


Fig.  346.— Contracture  in  ulnar  paralysis. 

ives  rise  to  this  kind  of  deformitv.     A  traumatic  origin  might. 


be  suspected  if  the  manus  valga  were  distinctly  unilateral. 


598  SURGICAL   DISEASES   OF   THE    EXTREMITIES 

C— ANOxMALIES   IN  THE  POSTURE  OF  THE  FIXGERS. 

We  mention  first  among  the  anomalies  of  posture  of  surgical 
interest,  the  bent  little  finger  which  is  sometimes  hereditary,  but  is 
a  cosmetic  fault  rather  than  a  deformity.  The  anomalies  of  posture 
which  may  supervene  after  trauma  and  after  tubercle  of  the  bones 
are  both  innumerable  and  irregular. 

Dupuytren's  contraction  of  the  palmar  aponeurosis  forms  quite 
a  characteristic  picture.  At  first  the  patient  merely  notices  that  he 
can  no  longer  fully  extend  his  fourth  and  fifth  fingers.  On  examina- 
tion there  will  be  found  a  localized  remarkably  hard  thickening  of 
the  palmar  aponeurosis  running  towards  the  affected  fingers.  The 
•skin  also  exhibits  swellings  alternating  with  retracted  areas.  The 
disease  usually  involves  both  hands  symmetrically,  or  one  becomes 
affected  soon  after  the  other.  Extension  of  the  affected  fingers 
becomes  more  and  more  difficult  ;  the  thick  swelling  continues  to 
■extend  towards  the  hand  and  the  fingers,  the  process  involving  one 
finger  after  another,  sometimes  even  the  thumb.  The  posture  of  the 
fingers  is  so  striking  that  it  cannot  be  overlooked  or  mistaken  for 
anything  else. 

In  rare  cases  an  injury  has  been  suggested  as  the  cause  ;  in 
other  cases,  a  tendency  to  gout  and  nervous  influence  have  been 
blamed,  and  I  have  seen  alcohol  suspected  in  more  than  one  instance. 
In  the  majority  of  cases  the  etiology  is  quite  obscure.  It  occasionally 
happens  that  a  contracture,  which  we  must  regard  as  Dupuytren's, 
is  said  to  have  come  on  after  an  injury  in  a  case  where  there  is  some 
prospect  of  compensation.  If  the  other  hand  also  shows  the  beginning 
of  a  contracture  we  must  not  then  attribute  much  significance  to  the 
unilateral  injury. 

We  may  also  refer  incidentally  to  the  trigger  fmger.  This  symptom 
-consists  of  the  arrest  of  the  movement  of  the  finger  in  a  certain  position 
and  its  sudden  advance  with  a  jerk  as  a  further  effort  is  made.  The 
■symptom  may  depend  upon  some  joint  disease,  e.g.,  on  some  abnor- 
mality in  the  shape  of  the  articular  ends  due  to  injury  or  inflammation. 
I3at  the  cause  is  usually  to  be  found  in  the  tendon  or  tendon-sheath, 
and  consists  of  a  localized  thickening,  which  produces  mechanical 
•obstruction  in  one  definite  position  of  the  finger. 


TUMOURS    OF   THE    HAND   AND    FINGERS  599 

CHAPTER    LXXXIX.  . 
TUMOURS    OF    THE    HAND    AND    FINGERS. 

,4._IXX0CEXT  TUMOURS. 

The  most  frequent  tumour-like  swelling  is  known  as  a  ganglion. 
As  we  now  know  that  these  structures  represent  areas  of  gelatinous 
degeneration  in  the  connective  tissue  of  the  joint  capsule,  and  arise 
independently  of  the  synovial  sheath  of  the  tendons  and  of  the 
joint,  we  no  longer  trouble  ourselves  to  difi'erentiate  between  tendo- 
genous  and  arthrogenous  ganglions.  They  have  nothing  to  do  with 
tendon  sheaths,  but  are  closely  related  to  the  joint  capsule,  because 
they  arise  within  its  tissue.  If  there  is  any  communication  present,  it 
must  have  arisen  secondarily.  It  follow^s  from  the  origin  of  the 
ganglion  that  its  cavity  is  only  separated  from  the  joint  cavity  by  a 
thin  layer  of  connective  tissue,  which  lies  directly  upon  the  synovial 
membrane.  Unless,  therefore,  we  proceed  with  the  utmost  care  in 
extirpating  a  ganglion,  we  must  be  prepared  for  opening  the  joint  over 
a  limited  area.  There  is,  of  course,  no  harm  in  this,  if  asepsis  is 
maintained. 

Some  quacks  tell  their  patients  that  a  "  nerve  is  displaced,"  in 
order  to  impress  them  with  the  belief  that  they  are  able  to  replace  it, 
I  know  of  a  quack  who  provided  every  disease  or  injury  of  the  limbs 
with  this  diagnosis,  and  nevertheless,  or  perhaps  because  of  it,  had  a 
large  clientele.  Voltaire  says,  quite  justly,  that  quackery  started  when 
the  first  swindler  discovered  the  first  fool. 

One  point  is  of  diagnostic  interest.  It  sometimes  happens,  in 
cases  of  tubercular  wrist,  that  granulation  masses  of  tubercle  protrude 
betw^een  the  tendons  as  far  as  the  skin,  as  visible,  separate  tumours. 
Oilier  has  described  cases  wherein  only  a  localized  protrusion 
of  the  capsule  has  become  affected  with  tubercle  (tuberculomes 
juxtasynoviaux). 

I  had  such  a  case,  in  which  the  wrist  movements  were  perfectly 
free,  and  1  proceeded  to  operate  in  the  belief  that  an  ordinary  ganglion 
was  present.     'Sly  mistake  only  appeared  during  the  operation. 

Cystic  tumours  of  the  hand  and  fingers  are  either  sebaceous  cysts, 
w^hich  are  usually  situated  on  the  dorsum,  or  traumatic  epithelial 
cysts,  which  are  always  found  in  the  palm.  The  latter  are  generally 
considered  to  be  due  to  some  trauma  which  has  displaced  some 
epithelial  cells  into  the  deeper  tissues. 

Franke  thinks  that  some  of  these  cysts  are  of  congenital  origin. 

Lipomata  are  generally  on  the  palmar  surface,  but  they  may  grow 
between  the  metacarpal  bones  and  appear  on  the  dorsum.  Like 
tuberculosis    of    the    tendon-sheaths,   they    may   spread    towards   the 


6oo 


SURGICAL   DISEASES    OF   THli   EXTREMITIES 


fingers,  but  in  contrast  thereto  they  always  come  to  a  termination  at 
the  carpal  ligament. 

Fibromata  always  present  their  usual  characters  :  they  are  well 
encapsuled,  are  hard,  and  grow  slowly  in  the  tissue  of  the  true  skin, 
the  palmar  aponeurosis,  the  tendon-sheaths  or  the  tendons.  They 
frequently  cause  neuralgic  pain. 

Angiomata  occur  in  every  variety,  as  telangiectases,  cavernous 
angiomata,  and  as  circinate  angiomata.  They  are  situated  in  the  skin, 
in  the  subcutaneous  connective  tissue  or  in  the  muscle.  Sometimes 
an  injury  appears  to  be  the  cause  of  the  origin  of  an  angioma. 

Chondromata  have  a  very  characteristic  appearance.  They  occur 
as  hard  nodulai-  growths  of  the  fingers,  and  are  often  multiple,  just  as 
those  which  occur  in  connection  with  the  toes  (which  see). 


Fig.  347. — Ganglion  of  wrist. 

Finally,  one  should  refer  to  a  small  inflammatory  tumour,  which  is 
.occasionally  found  on  the  hand  or  fingers.  It  is  about  the  size  of  a 
-pea,  or  somewhat  larger,  resembles  a  raspberry  in  appearance,  has  a 
-thin  stalk  and  is  surrounded  by  a  collar  of  epidermis.  It  is  a 
granuloma,  first  described  by  Poncet  and  Berard  as  botriomycosis, 
and  is  essentially  a  disease  of  horses.  The  one  observer  attributed  it 
to  a  definite  variety  of  Staphylococcus  botriouiyces ;  the  other,  to  the 
Stapliylococcns  aureus.  The  appearance  of  the  tumour  is  so  charac- 
teristic that  it  cannot  be  mistaken  if  once  seen.  Histologically,  it  is 
a  telangiectatic  granuloma. 

B.— MALIGNANT   TUMOURS. 

The  principal  malignant  tumours  which  occur  on   the  hands  and 
fingers  are  sarcomata  and  cancer  of  the  skin. 

Sarcomata    have    been  seen  on  all  parts  of  the   hand,    but  most 


ACUTE  IXFLA-MMATORY  PROCESSES  OF  THE  HAND  AND  FIXGERS      6ol 

frequently  on  the  fingers.  They  may  arise  in  the  skin,  in  the  tendons 
or  tendon-sheaths,  or  in  the  bones,  in  which  latter  case  they  may  be 
mistaken  for  chrondromata. 

Cutaneous  cancer  always  occurs  on  the  back  of  the  hand.     It 
appears  at  first  as  a  flat,  more    or    less   warty  growth,   which  subse- 


FlG.  348. — Cancer  of  the  back  of  hand. 

quently  ulcerates  extensively  and  assumes  the  usual  characters  of 
cancer  (see  fig.  348).  Cutaneous  cancer,  arising  from  chronic  X-ray 
dermatitis,  or  from  localized  hyperkeratosis  independently  thereof, 
deserves  special  mention,  as  many  well-known  radiographers  have 
fallen  victims  to  it. 


CHAPTER   XC. 

ACUTE   INFLAMMATORY   PROCESSES    OF    THE 
HAND   AND    FINGERS. 

.4.— INFLAMMATORY  PROCESSES  OF  THE  FIXGERS. 

Although  inflammatory  processes  of  the  hand  and  fingers  are 
routine  matters  of  minor  surgery,  they  do  occasionally  raise  interesting 
problems. 

If  a  patient  comes  with  a  swollen  and  inflamed  finger,  as  a  rule 
we  diagnose  a  whitlow  forthwith.  But  this  does  not  complete  our 
diagnostic  task.  Several  diseases  sail  under  the  flag  of  whitlow,  and 
we  shall  deal  with  them  briefly. 

We  must  anticipate,  by  insisting  upon  a  careful  examination  for 
lymphangitis  of  the  arm,  and  enlarged  glands  of  the  axilla,  in  every  case 


602  SURGICAL   DISEASES   OF   THE    EXTREMITIES 

of  infective  disease  of  the  fingers.  A  trifling  wound  of  the  finger, 
which  may  have  been  healed  within  a  few  days,  can  lead  to  enlarged 
glands  of  the  axilla  and  subsequent  suppuration. 

(a)  Dermatitis. — A  patient  consults  us  for  a  severely  swollen  and 
inflamed  middle  finger,  which  looks  more  hke  a  beetroot  than  anything. 
else.  He  states  that  he  had  sustained  a  slight  injury  to  the  skin, 
which  he  treated  by  lysol  fomentations  on  the  direction  of  his  doctor. 
The  finger  became  swollen,  and  as  the  swelling  increased,  the  more- 
assiduous  was  he  with  the  lysol  fomentations.  It  is  clear  on  examina- 
tion that  the  two  contiguous  surfaces  of  the  neighbouring  fingers  are 
inflamed,  in  addition  to  the  middle  finger.  There  is  no  extension  of 
the  inflammation  to  the  hand  or  the  arm  in  the  form  of  lymphangitis  ;. 
neither  are  there  any  general  symptoms  of  infection.  There  is  no 
sign  of  disease  in  the  bone  or  tendon  sheath,  and  the  original  wound 
is  almost  healed.  Considering  the  entire  condition,  and  especially 
the  involvement  of  the  two  contiguous  surfaces  of  the  adjoining 
fingers,  we  are  bound  to  assume  that  the  case  is  one  of  drug" 
dermatitis.  The  abandonment  of  all  disinfectants  and  a  dressing  of 
simple  ointment  soon  caused  all  the  symptoms  to  disappear. 

A  similar  condition  may  attend  other  disinfectants,  for  instance 
corrosive  sublimate,  and  especiallv  iodoform.  Iodoform  dermatitis- 
was  a  very  common  occurrence  when  the  practitioner  used  to  think 
that  he  had  not  discharged  his  duty  adequately  unless  his  patient 
reeked  of  iodoform. 

Where  the  infective  inflammation  is  deeply  seated,  the  skin  is 
tense  and  elastic,  the  epidermis  smooth  and  shining.  In  drug 
dermatitis  the  superficial  epidermis  is  infiltrated,  uneven  and  rather 
rough,  and  is  often  raised  by  numerous  little  definite  vesicles,  or  even 
by  large  blebs. 

I  once  saw  a  slight  wound  of  the  finger,  treated  by  sublimate 
compresses  to  prevent  infection,  which  resulted  in  bulbous  der- 
matitis reaching  to  the  shoulder.  The  whole  arm  resembled  an 
enormous  sausage  and  was  covered  all  over  with  blisters.  In  this 
case  also  the  patient  applied  the  compresses  the  more  diligently  as 
the  dermatitis  mcreased. 

If  the  infection  is  deeply  situated  the  patient  complains  of  a 
stabbing,  boring,  aching  pain,  which  prevents  any  rest,  either  by  day 
or  night  ;  in  dermatitis,  however,  the  complaint  is  rather  of  a  trouble- 
some irritation  and  burning.  In  the  former  case  local  pressure  causes 
great  pain,  in  the  latter  case  very  little. 

(b)  Primary  inflammations  of  the  bed  of  the  nail.  If  the  in- 
flammation starts  superficially  at  a  circumscribed  spot  and  gradually 
spreads  to  the  whole  phalanx,  the  case  is  one  of  infection  of  the  nail- 
bed,  even  if  the  bone  necroses  subsequently. 

If  the  inflammation  does  not  involve  the  bone,  and  nevertheless 
fails  to  subside  in  the  ordinary  manner,  w^e  should  remember  that  a 
primary  chancre  has  often  been  mistaken  for  a  whitlow,  and  also  that 


ACUTE  INFLAMMATORY  PROCESSES  OF  THE  HAND  AND  FINGERS       603 

there  is  such  a  condition  as  paronychia  syphilitica,  in  the  secondary 
stage.  If  the  patient  exhibits  a  striking  tendency  to  whitlows,  although 
his  occupation  does  not  predispose  towards  them,  we  should  examine 
for  syringo-myelia  (fig.  352),  Raynaud's  disease,  and  diabetes.  An 
ordinary  whitlow,  which  runs  a  particularly  severe  course,  is  always 
suggestive  of  diabetes. 

(c)  An  inflammation  situated  in  the  subcutaneous  cellular  tissue 
is  distinguished  from  one  due  to  primary  disease  of  the  bone  by  the 
fact  that  it  is  of  very  limited  extent  at  first.  If  the  accumulation  of 
pus  is  not  incised  early,  the  inflammation  may  attack  the  tendon- 
sheaths  and  then  rapidly  extend. 

(d)  We  must  also  refer  to  erysipelatoid  inflammation  of  the  finger, 
which  was  described  by  Rosenbach  and  more  recently  by  Tavel, 
cases  of  which  we  have  ourselves  observed.  Redness  and  hard  swell- 
ing of  the  skin  develop  as  a  result  of  some  insignificant  wound  of 
the  skin,  and  the  condition  slowly  spreads  towards  the  hand,  without 
leading  to  suppuration  or  causing  general  symptoms.  In  other  cases 
lymphangitis,  painful  swelling  of  the  axillary  glands,  and  pyrexia  occui". 
The  disease  is  very  liable  to  recurrence,  and  people  who  are  occupied 
with  meat,  or  animal  oft'al,  are  the  most  frequent  sufferers. 

(e)  We  now  come  to  acute  inflammations  of  the  tendon  sheaths. 
These  do  not  usually  arise  spontaneously,  but  follow  some  injury, 
extending  as  far  as  the  tendon-sheath.  Perforating  wounds  and  bites 
are  especially  dangerous  in  this  respect,  because  if  they  introduce 
septic  organisms  in  deep  situations,  they  are  not  easily  dislodged,  and 
have  abundant  opportunity  of  developing  undistiu-bed. 

If  swelling  of  the  finger  occurs  after  such  a  history,  the  course  of 
the  tendon-sheath  should  be  noted  and  an  rmmediate  opening  made, 
without  waiting  for  definite  fluctuation,  if  there  is  pain  on  pressure 
along  the  sheath. 

Teno-synovitis  is  distinguished  in  its  early  stages  from  ostitis  and 
periostitis  by  the  fact  that  the  inflammation  is  not  limited  to  the 
course  of  one  phalanx,  and  that  the  pain  on  pressure  and  the  swelling 
are  more  pronounced  on  one  side  of  the  finger  than  on  the  other. 
The  distinctness  of  the  clinical  picture  often  becomes  obliterated  in 
the  more  advanced  stages,  because  a  periostitis  may  develop  from  a 
teno-synovitis,  and  a  secondary  inflammation  of  the  tendon-sheath  mav 
follow  primary  disease  of  the  bone.  If  an  injury  can  be  excluded, 
gonorrhoea  should  be  thought  of.  Gonorrhoeal  teno-synovitis  usually 
begins  very  acutely,  almost  like  a  phlegmon,  and  then  proceeds  to  a' 
■quiet  chronic  stage.    Suppuration  occurs  especially  \n  mixed  infections. 

If  a  manual  labourer  complains  of  a  slightly  painful  swelling  over 
the  long  extensor  of  the  thumb,  which  has  come  on  alter  hard  work, 
and  we  feel   distinct    crepitation   over    the  tendon    and    muscle,  the 

39 


6o4 


SUR(}ICAL    DISEASES    OF   THE    EXTREMITIES 


diagnosis  is  crepihiiit  tciio-s\'iioviti<,  a  tibrinous  inflammation  of  the 
tendon-sheath,  the  tissue  around  the  tendon  and  the  muscle. 

(/)  Suppurative  inflammation  of  the  bone,  whether  primary  or 
secondary,  can  be  recognized  : — 

(ij  By  tlie  diffuse  swelling  and  tenderness  of  the  entire  circum- 
ference of  the  finger,  in  the  extent  of  one  phalanx. 

(2)  By  pain  on  axial  pressure. 

(3)  By  false  mobility  and  crepitus  in  the  adjacent  joint,  as  the 
disease  progresses. 

A  skiagram  is  of  no  assistance  in  the  initial  stage,  but  is  yery 
yaluable  later  on,  when  the  course  is  protracted  and  there  is  a  deyelop- 


Fjg.  349. — Whitlow  causing 
secondary  disease  of  bone. 
Infection  of  extensor  tendon 
sheath  by  prick  of  a  needle. 


Fig.  350.  —  Skiagram 
of  same.  X  =^  part  of 
bone  which  has  formed  a 
sequestrum. 


ment  of  new  periosteal  bone,  or  an  inyolucrum  begins  to  form,  or 
if  the  case  is  somewhat  more  acute  and  the  dead  bone  becomes 
divided  from  the  heahhv  part  by  a  light  zone,  even  without  the 
formation  of  any  new  bone  (tig.  350). 

{g)  It  is  important  to  know  something  about  acute  inflammation 
of  the  finger  joints.  The  first  interphalangeal  joint  is  most  fre- 
quently affected.  It  acquires  a  spindle-shaped  thickening  and  looks 
somewhat  like  a  radish  in  form.  It  is  usually  the  consequence  of 
some  injury,  and  I  have  seen  it  particularly  in  butchers.  The  joint 
may  remain  distended  with  clear  fluid  for  weeks  after  the  subsidence 
of  acute  symptoms,  even  in  mild  cases.  If  the  disease  lasts  for  a  long 
time,  the  cartilage  finally  disappears,  as  may  be  demonstrated  by 
X-rays,  before  the  joint  yields  any  crepitus  on  movement.     Conor- 


CHROXIC   IXFLAMMATIOX    OF   THE    HAND   AXD    FINGERS  605 

rhoea  should  be  thought  of  if  only  one  joint  is  afiected,  and  if  the 
disease  has  had  a  sudden  and  spontaneous  onset. 

The  finger-joints  may  be  involved  secondarily  in  cases  of  suppurative 
teno-synovitis  and  ostitis.  The  clinical  picture  is,  however,  dominated 
in  such  circumstances  by  the  primary  disease,  and  the  arthritis  is 
merely  a  complication. 

Z?.— ACUTE  INFLAMMATORY   PROCESSES   OF  THE   HAND. 

These  arise  from  three  different  causes,  leaving  out  of  account  the 
rare  cases  of  primary  periostitis  and  osteomyelitis  of  the  metacarpal 

bones.  They  may  originate  as  an  extension  from  the  fingers,  as  a 
result  of  injuries  to  the  hand,  or  from  suppuration  of  the  bursa, 
which  exists  so  frequently  in  the  case  of  manual  labourers,  under  the 
callosities  of  the  palm.  The  diagnosis  is  usually  very  easy,  but  one 
must  remember  that  even  if  the  site  of  inflammation  be  in  the  palm, 
the  oedema  is  most  intense  in  the  dorsinn,  because  of  the  greater  laxitv 
of  the  skin.  This  peculiarity  often  leads  the  beginner  to  make  his 
incision  in  the  wrong  place. 

The  practitioner  often  has  to  decide  whether  suppurative  inflam- 
mation of  the  bursa  beneath  callosities  is  the  result  of  an  accident  or 
not.  If  a  wound  of  the  skin,  however  minute,  has  led  to  infection, 
the  decision  is  clear  enough.  But  suppuration  occasionallv  occurs 
without  it  being  attributable  to  such  a  cause,  and  we  are  bound  to 
regard  it  as  a  malady  arising  from  occupation,  and  not  as  the  conse- 
quence of  an  accident. 

It  should  be  mentioned  that  an  acute  attack  of  gout  mav  excep- 
tionally occur  in  the  hand. 

I  have  seen  such  a  case  incised  as  phlegmon — a  mistake  which 
may  be  pardoned  owing  to  the  rarity  of  the  incident. 


CHAPTER    XCI. 


CHRONIC  INFLAMMATION  OF  THE  HAND  AND 

FINGERS. 

The  skin,  the  tendon  sheaths,  the  bones  or  the  joints  may  be  the 
seat  of  chronic  inflammation  in  the  hand  or  fingers. 

(1)  THE   SKIN. 

Chronic  inflammatory  conditions  of  the  skin  and  subcutaneous 
tissue  include  primary  chancre,  lupus,  leprosy,  syringo-myelia,  the 
trophic  disturbances  associated  with  Raynaud's  disease,  in  addition  to 


6o6  SURGICAL   DISEASES    OF   THE    EXTREMITIES 

chronic  eczema  and  to  gumma,  which  latter  is,  however,  of  rare 
occurrence. 

A  chancre  may  be  diagnosed  by  the  history,  early  enlargement  of 
the  glands,  and  possibly  by  the  secondary  symptoms.  Many  a  prac- 
titioner has  fallen  a  victim  to  a  primary  sore  of  the  hand  in  the 
course  of  his  profession. 

Practitioners  who  cannot  restrain  themselves  from  touching  every 
wound  or  ulcer  with  their  lingers,  may  be  reminded  that,  even  if  they 
do  not  fear  the  organisms  of  suppurations,  they  may  still  be  in  dread 
of  the  spirochcctes.  A  well-known  dermatologist  says,  not  unjustly, 
"  Whoever  touches  ever}^  ulcer  with  his  fingers,  shows  that  he  does 
not  know  what  it  may  be,  or  that  he  has  already  had  syphilis."  If  the 
ulcer  must  be  touched,  an  india-rubber  finger-stall  should  be  used,  for 
the  protection  of  oneself  and  other  patients. 


Fig.  351. — Lupus  of  back  of  hand.      (Tuberculosis  verrucosa  cutis.) 

Lupus,  in  its  various  forms,  is  mostly  situated  on  the  back  of  the 
hand  or  fingers.  It  is  recognized  by  its  usual  characteristics,  and  we 
would  especially  refer  to  what  has  already  been  said  in  connection 
with  lupus  of  the  face,  for  the  points  of  distinction  between  it  and 
tertiary  syphilitic  lesions.  Lupus  may,  in  rare  cases,  ulcerate  very 
deeply  and  even  destroy  the  tendons,  eventually  causing  severe  con- 
tractures. If  the  tubercular  process  attacks  the  bones  and  joints, 
there  may  ensue  an  amount  of  destruction  which  is  suggestive  of 
leprosy. 

Post-mortem  tubercle  and  skin  tuberculosis  of  butchers  should  also 
be  thought  of,  if  the  appropriate  causes  exist. 

Leprosy  of  the  fingers  is  chiefly  recognized  by  the  fact  that  it 
leads  to  their  spontaneous  amputation.  If  this  condition  exists  we 
must  at  once  ascertain  whether  the  patient  has  lived  in  a  leprosy 
district.     In  addition  to  the  well-known  regions  of  leprosy,  there  are 


CHROXIC    INFLAMMATION   OF   THE   HAND   AND    FINGERS 


607 


numerous  scattered  centres  of  leprosy  in  rarely  visited  districts,  which 
should  be  taken  into  consideration.  In  doubtful  cases,  we  must 
search  for  traces  of  macular  leprosv  in  persistent,  atrophic,  superficial 
and  cicatricial  cutaneous  changes  in  various  parts  of  the  body,  and  in 
thickening  of  the  large  nerves,  especially  the  ulnar. 

The  mutilation  in  syringo-myelia  and  Raynaud's  disease  compete 
with  that  in  leprosy.  The  symmetry  and  the  associated  nerve 
symptoms  are  always  conclusive.  The  latter  must,  however,  be 
carefully  sought  for,  because  the  patient  is  often  quite  unaware  of 
them  (see  fig.  352,  which  is  taken  from  a  patient  who  had  no 
intimation  of  his  syringo-myelia). 

(2)  THE  TENDON-SHEATHS. 

Inflammation  of  the  tendon- 
sheaths,  which  is  chronic  from  the 
start,  and  which  is  accompanied 
by  swelling,  is,  practically  without 
exception,  of  a  tubercular  nature. 
The  flexor  tendons  are  most  fre- 
quently affected. 

I  once  saw  a  case  of  extensive 
tubercular  teno  -  synovitis  of  the 
extensor  tendons  in  a  butcher,  who 
had  wounded  himself  on  the  cor- 
responding place  fifteen  years  pre- 
viously with  a  splinter  of  bone  of 
a  tubercular  cow.  An  old  scar  still 
remained  in  evidence  of  the  wound. 

Tubercular  teno  -  synovitis  is 
easily  recognized  by  the  puffy 
induration  in  the  region  of  the 
tendon-sheath  and  by  the  stiffness 
of  the  corresponding  finger  on  slight  flexion  (fig.  335).  The  common 
tendon-sheath  under  the  anterior  annular  ligament  is  occasionally 
affected,  and  the  disease  extends  therefrom  in  four  processes  to  the 
second,  third,  fourth  and  fifth  fingers.  There  is  frequently  no 
fluctuation,  or  it  may  be  more  or  less  clearly  recognizable  in  the  palm 
only.  If  there  is  any  considerable  effusion  the  sac  is  subdivided, 
being  constricted  by  this  ligament  just  mentioned.  The  fluid  can  be 
displaced  from  the  palm  to  the  forearm  and  vice  versa.  Crepitation 
indicates  the  formation  of  melon-seed  bodies.  At  first,  the  tendon 
sheaths  only  are  affected,  but  spindle-shaped  areas  of  granulation 
tissue  with  separation  of  the  tendon-tissue  into  brush- like  masses, 
may    develop    in    course    of    time.       Chronic    enlargement    of    the 


Fig.  352. — Mutilation  of  hand,  due  to 
syringo-myelia. 


6o8  SURGICAL   DISEASES    OF   THE    EXTREMITIES 

axillary    glands    confirms   the    diagnosis,    if    confirmation    should  be 
necessary. 

Tubercle  could  only  be  mistaken  for  the  subacute  stage  of 
gonoi'i'ha'al  tenosynovitis  ov  for  the  much  more  rare  lipoma  of  the  palm. 
The  former  would  be  indicated  by  a  sudden  onset  with  severe  pain  ; 
the  latter  by  a  painless  onset. 

We  must  still  refer  to  another  malady,  which  mav  cause  the  patient 
much  agony,  although  it  is  trifling,  and  easy  to  relieve.  This  consists 
of  the  relative  narrowness  of  the  compartment  of  the  tendon-sheath, 
lying  on  the  styloid  process  of  the  radius,  which  transmits  the  extensor 
pollicis  brevis  and  the  abductor  poUicis  longus — a  condition  which  I 
first  described  sixteen  years  ago,  at  Kocher's  suggestion,  as  contracting 
teno-synovitis.  It  is  not  an  inflammation  in  the  strict  sense  of  the 
term.  The  patients,  who  are  mostly  females,  coinplain  of  pains 
radiating  towards  the  thumb  and  forearm  on  any  effort.  On  physical 
examination,  the  only  thing  to  be  noted  is  a  striking  tenderness  on 
pressure,  and  sometimes  a  slight  swelling  in  the  vicinity  of  the  above- 
mentioned  compartment  of  the  tendon-sheath. 

If  the  tendon-sheath  is  exposed  under  local  anaesthesia,  the 
tendons  are  seen  to  be  constricted  within  it.  The  sheath  should  be 
split,  which  may  also  be  done  subcutaneously  with  a  tenotome,  and 
the  patient  is  immediately  and  permanently  cured.  Histological 
examination  merely  shows  thickening  of  the  wall  of  the  sheath, 
without  an}^  inflammatory  changes. 

(3)  THE    BONES. 

A  spindle-shaped  swelling  of  a  metacarpal  bone  or  a  phalanx, 
which  has  developed  gradually  and  with  little  pain,  and  which 
eventually  suppurates  and  forms  a  sinus,  is  almost  always  tubercle. 
We  say  almost,  because  there  is  a  very  similar  condition  of  the 
phalanx,  which  is  due  to  syphilitic  dactylitis.  But  the  mere  diagnosis 
of  tubercular  disease  does  not  exhaust  all  that  is  necessary  to  know. 
From  the  point  of  view  of  prognosis,  it  is  important  to  ascertain 
whether  the  disease  has  started  in  the  medulla  or  in  the  periosteum. 
In  adults  the  origin  is  usually  periosteal,  but  in  children  almost 
exclusively  medullar3\ 

My  impression  is  that  children  who  are  the  subject  of  congenital 
syphilis  also  display  the  periosteal  variety  of  tuberculosis  more 
frequently.  Whether  this  is  actually  a  fact  must,  however,  remain  an 
open  question. 

The  fate  of  the  finger  difters  in  the  various  forms  of  the  disease. 
In  tubercle  arising  from  the  medulla,  ordinary  tubercular  dactylitis 
(fig.  354),  the  bone  becomes  more  and  more  distended,  or,  to  put  it  more 
accurately,  becomes  destroyed  internally  and  is  replaced  by  new  bone 
from  the  periosteum.     In  this  condition,  the  periosteum  may  remain 


CHKONIC   INFLAMMATION   OF   THE    HAND   AND    FINGERS  609 

at  least  partially  healthy.  The  spongy  tissue  becomes  absorbed,  or 
forms  a  sequestrum  which  is  either  expressed  spontaneously  or 
removed  surgically.  The  phalanx  becomes  bent  to  one  side,  but 
practically  the  whole  of  it  remains.  In  the  periosteal  form,  however, 
the  whole  diaphysis  gradually  becomes  deprived  of  its  nutrition 
(fig.  353),  necroses,  and  is  expressed  or  removed  surgically  after  pro- 
longed suppuration.  But  as  the  periosteum  itself  is  tubercular,  no 
healthy  involucrum  is  formed  as  in  the  case  of  staphylococcic  osteo- 
myelitis, but  the  linger  becomes  shortened  by  about  the  length  of  the 


■:'% 


Fig.  353. — Tubercular  dactylitis  of  periosteal 
origin. 


Fig.  354. — Tubercular  dactylitis  of  medullary  origin. 


diaphysis,  after  a  few  splinters  of  bone,  formed  from  the  periosteum, 
have  been  removed  as  sequestra. 

The  differential  diagnosis  between  these  two  forms  cannot  be 
made  clinically,  at  any  rate  as  long  as  there  is  no  fistula.  It  can,  how- 
ever, be  made  by  a  skiagram,  upon  which  we  must  always  base  our 
treatment. 

If  there    is  a  history  of  congenital    syphilis  or  a  positive  serum 


6lO  SURGICAL    DISEASES    OF   THE    EXTREMITIES 

reaction,  the  probability  of  syphilitic  dactylitis  is  indicated.  There  is, 
however,  no  certain  clinical  symptom,  and  every  case,  which  is  not 
clearly  one  of  tubercle,  but  in  which  there  is  some  suspicion  of 
syphilis,  should  have  specific  treatment  before  any  other  course  is 
undertaken. 


CHAPTER   XCII. 
DISLOCATIONS  AND  FRACTURES  OF  THE  HIP. 

There  is  no  joint  which  presents  so  much  difticulty  to  the 
beginner,  and  sometimes  also  to  the  experienced,  as  the  hip,  because 
of  the  inaccessibility  of  the  articular  ends  both  to  sight  and  to  palpa- 
tion. All  conclusions  relating  to  the  joint  are,  therefore,  necessarily 
based  on  indirect  signs,  and  the  hip  thus  places  a  severe  tax  on  the 
diagnostic  powers  of  the  examiner. 

The  most  striking  symptom  of  all  hip  diseases  is  limping  ;  and  we 
shall  therefore  briefly  consider  the  most  important  forms  of  this 
symptom.  The  simplest  variety  is  that  which  follows  shortening. 
In  this  condition,  the  body  inclines  towards  the  diseased  side  at 
every  step  ;  not  because  the  limb  gives  way,  but  because  it  is  too 
short.  The  leg  is  by  no  means  spared,  but  still  serves  as  a  normal 
support.  If  the  shortening  is  slight,  the  complete  sole  is  planted 
down,  but  if  it  is  extreme,  only  the  toes  reach  the  ground.  The  limp 
becomes  noticeable  in  adults  if  the  shortening  exceeds  i^  cm.  (f  in.). 

The  paralytic  limp,  in  the  widest  sense  of  the  term,  is  very  similar. 
The  limb  is  insufficiently  supported,  either  because  of  muscular 
weakness  or  because  of  dislocation.  The  patient  supports  himself 
vigorously  on  the  affected  leg,  evidently  experiences  no  pain  therein, 
but  inclines  with  each  step  towards  the  diseased  side,  and  then 
supports  himself  the  more  firmly  on  the  healthy  leg  for  the  purpose 
of  throwing  the  diseased  leg  forwards  for  the  next  step.  If  this 
variety  of  limping  is  due  to  congenital  dislocation,  the  head  of  the 
thigh  bone  may  be  seen  to  move  upwards,  under  the  gluteal  muscles, 
towards  the  pelvis.  If  the  disease  is  bilateral,  the  gait  is  waddling, 
like  that  of  a  duck. 

Painless  stiffness  of  one  hip  produces  quite  a  different  kind  of 
limp.  The  entire  extremity,  includmg  the  half  of  the  pelvis,  is  moved 
forward  as  a  whole,  because  a  normal  function  of  the  other  joints  is 
not  conceivable  if  one  joint  is  stiff.  But  as  there  is  no  pain,  the 
limb  is  not  spared  as  a  means  of  support,  and  the  weight  of  the  body 
is  equally  received  by  both  legs.  If  the  patient  walks  slowly,  he  is 
therefore  able  to  render  his  disability  less  noticeable.  The  gluteal 
fold  is  obviously  obliterated  on  the  diseased  side.     A  peculiar  gait  is 


DISLOCATIONS   AND    FRACTURES   OF   THE    HIP  6ll 

produced  by  bilateral  stiffness  of  the  extremities  as  in  cases  ot 
severe  double  coxa  vara.  The  patient  wearily  moves  forwards,  first 
one  half  and  then  the  other  half  of  the  pelvis  alternately,  and  there- 
with the  corresponding  limb.  The  pelvis  rotates  around  a  vertical 
axis,  and  not  around  a  sagittal  axis,  as  in  cases  of  bilateral 
dislocation. 

In  cases  of  painful  limping,  the  movement  of  any  joint  is  painful, 
and  as  all  the  joints  of  the  lower  limb  are  interdependent — for 
instance,  a  twisting  movement  of  the  foot  is  impossible  without  the 
participation  of  the  knee  and  hip  joints — the  patient  stiffens  all  the 
joints  by  muscular  action,  and  avoids,  as  far  as  possible,  putting  any 
weight  on  the  diseased  limb,  and  inclines  his  body  towards  the  healthy 
side.  This  latter  circumstance  distinguishes  painful  limping  from 
limping  due  to  painless  rigidity,  for  otherwise  most  of  the  symptoms 
are  common  to  both  conditions,  including  especially  the  obliteration 
of  the  gluteal  fold. 

There  are  several  types  of  disturbance  in  gait.  In  unilateral 
congenital  dislocation,  it  depends  upon  shortening  and  laxity  of  the 
joint ;  in  old  hip  disease,  it  depends  upon  shortening  and  stiffness. 

Doubt  should  rarely  arise  as  to  whether  an  injury  to  the  hip-joint 
consists  of  a  dislocation  or  a  fracture.  As  a  rule,  such  doubt  indicates 
that  the  examination  has  not  been  conducted  properly,  or  that  the 
physical  condition  has  not  been  correctly  understood.  In  order  not 
to  fail  in  the  appreciation  of  indispensable  anatomical  points,  every 
practitioner  should  possess  a  skeleton,  and  he  should  consult  it 
frequently.  Expenditure  on  this  is  by  far  more  advisable  than  on 
instruments  which  the  practitioner  purchases  on  the  recommendation 
of  manufacturers,  but  rarely,  if  ever,  uses. 

.4.— METHOD    OF    EXAMINATION. 

We  begin  with  inspection,  and  note  the  position  and  posture  of  the 
injured  limb  as  well  as  the  external  visible  injuries,  extravasations  of 
blood  and  swellings. 

The  experienced  observer  will  often  be  able  to  make  a  diagnosis 
from  the  posture  of  the  injured  extremity,  or  at  least  will  narrow  down 
the  possibilities  to  a  very  limited  extent.  Thus,  if  the  injured  person 
lies  helpless  and  motionless,  with  his  leg  in  a  state  of  complete 
external  rotation,  he  will  at  once  think  of  a  fracture  below  the  neck  of 
the  femur.  A  flexed  thigh,  rotated  internally  and  adducted,  will 
suggest  a  dislocation.  He  will  also  notice  whether  the  region  of  the 
hip,  on  the  injured  side,  is  drawn  in,  or  whether  it  projects  unnaturally. 
A  roundish  bulging  in  the  inguinal  region  is  not  likely  to  escape  him 
any  more  than  the  fact  of  the  one  patella  being  higher  than  the  other 
- — a  condition  which  indicates  shortening. 

We  next  proceed  to  what  is  for  the  patient  the  least  painful  pro- 
cedure of  examination,  the  measnrenient  of  the  length  of  the  limb,  and 


6l2  SURGICAL    DISEASES    OF   THE    EXTREMITIES 

tor  this  purpose,  it  is  necessary  to  bring  both  Hmbs  into  exactly 
the  same  position,   to  avoid  mistakes. 

We  measure  on  both  sides  the  distance  (i)  between  the  anterior 
superior  spine  of  the  ihum  and  the  tip  of  the  external  malleolus  (c  in 
lig.  355)  and  (2)  the  distance  between  the  tip  of  the  trochanter  and 
the  malleolus  (b).  (In  cases  of  extreme  external  rotation  the  first 
measurement  is  also  taken  to  the  internal  malleolus.)  If  the  measure- 
ments are  equal  on  both  sides,  we  may,  as  a  rule,  exclude  anv  change  in 
the  bone,  provided  that  the  limb  used  as  the  standard  for  comparison 
has  not  been  shortened  by  a  previous  accident.  If  one  or  other  of 
these  measurements,  or  both  of  them,  be  shortened,  there  is  certainly 
either  a  dislocation  or  a  fracture,  unless  the  shortening  be  due  to  some 
previous  injury  or  disease.  If  the  distance  between  the  anterior 
superior  spine  and  malleolus  (c)  is  alone  shortened  (supra-trochanteric 
shortening)  the  case  is  either  one  of  dislocation  or  fracture  of  the  neck 
of  the  femur.  If  both  measurements  b  and  c  are  shortened,  the 
-reparation  of  continuity  must  be  below  the  tip  of  the  trochanter  (infra- 
trochanteric  shortening),  and  the  case  can  only  be  one  of  fracture 
below  the  tip  of  the  trochanter. 

We  next  determine  the  relation  of  the  trochanter  to  the  pelvis,  in 
order  to  control  the  measurements  previously  obtained.  It  is  generally 
said  that  for  this  purpose  the  most  important  thing  is  to  ascertain 
Roser-Nelaton's  line.  Unfortunately,  it  is  very  difficult  to  do  this 
when  the  injury  has  been  severe.  It  is  better  to  make  use  of  this  line 
in  cases  of  abnormal  positions,  of  iion-irauniatic  origin.  In  recent 
injuries  we  should  adopt  other  measurements  which  are  equally  reliable 
and  easier  to  carry  out,  and  which  do  not  demand  any  change  of 
posture  in  the  injured  person.  These  measurements  consist  of 
Bryant's  triangle  andthe  trochanter — anterior  superior  spine — umbilicus 
line,  which  will  be  referred  to  in  detail  in  the  next  section.  The 
determination  of  Bryant's  triangle  is  of  special  significance  because 
the  measurement  of  the  horizontal  base  line  of  this  triangle  intimates 
t(j  us  the  alteration  in  the  position  of  the  trochanter,  and  gives  its 
level,  and  thus  enables  us,  by  comparing  the  two  sides,  to  ascertain 
how  far  tlie  trochanter  has  been  displaced  upwards. 

If  the  trochanter  is  abnormally  high,  there  is  either  a  dislocation 
or  a  fracture  of  the  neck  of  the  femur.  If  it  is  in  a  normal  position 
the  injury  is  not  associated  with  any  displacement,  or,  if  there  be  any, 
it  must  be  below  the  trochanter. 

In  slight  bending  of  the  neck  of  the  femur,  or  in  fractures  which 
are  slighth'  impacted,  the  shortening  may  be  so  small  in  amount  as 
to  come  within  the  ordinary  limits  of  errors  of  measurement.  In 
anterior  dislocations  the  trochanter  is  not  displaced  upwards  in  any 
marked  degree.  But  in  these  cases,  its  definite  approximation  to  the 
mid-line  of  the  body  shows  that  some  anatomical  damage  has  been 
sustained.  We  also  find  a  certain  amount  of  approximation  to  the 
middle  line  in  impacted  fractures  of  the  neck  of  the  femur.  But,  as 
we  shall  see  later  on,  there  are  other  definite  signs  which  distinguish 
these  fractures  from  anterior  dislocations. 


DISLOCATIONS   AXD    FRACTURES    OF   THE    HIP 


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6l4  SURGICAL   DISEASES   OF  THE    EXTREMITIES 

After  ascertaining  the  measurements  of  the  hmb,  we  must  deter- 
mine the  range  of  active  movements. 

For  this  purpose,  the  patient  must  he  flat  in  bed,  undressed,  and 
endeavour  to  raise  the  injured  hmb  in  the  position  of  extension.  If 
he  can  do  this  without  hesitation,  although  there  may  be  pain,  there 
is  certainly  neither  dislocation  nor  fracture.  A  sprain  or  a  contusion 
is  the  most  likely  thing.  If  he  flexes  the  thigh  with  difficulty,  without, 
however,  raising  the  heel  from  the  bed,  the  case  may  probably  be  one 
of  impacted  fracture.  We  then  ask  the  patient  to  perform  movements 
of  rotation.  If  external  and  internal  rotation  are  perfectly  free,  there 
can  be  no  severe  injury  present.  But  if  there  is  a  definite  limitation 
of  active  internal  rotation,  whereas  outward  rotation  appears  to  be 
normal,  or  even  exceeds  the  normal  in  extent,  the  case  is  probably 
one  of  impacted  fracture  of  the  neck  of  the  femur.  If  no  active 
movements  of  rotation  are  possible  and  at  the  same  time  the  limb  is 
turned  outwards,  there  is  probably  a  fracture  below  the  trochanter. 
But  if  the  external  rotation  is  not  complete,  and  some  trace  of  active 
power  of  rotation  still  persists,  the  probabihty  is  that  the  case  is  one 
of  non-impacted  fracture  of  the  neck  of  the  femur. 

We  cannot  elicit  much  information  from  abduction  and  adduction 
movements,  because  the  raising  of  the  whole  leg  is  necessary  to 
perform  them.  But  the  same  remarks  apply  to  these  movements  as 
to  rotatory  movements. 

We  now  proceed  to  passive  movements,  which  must  perhaps  be 
carried  out  under  anaesthesia.  It  is  obvious  that  the  manipulations 
must  be  performed  with  the  greatest  care,  lest  a  useful  impaction- 
becomes  separated  in  the  process. 

If  passive  movements  are  free,  or  only  slightly  hampered  on  in- 
ternal rotation,  the  case  is  certainly  one  of  fractnre,  assuming  that  a 
severe  injury  has  been  sustained.  If  the  movements  exceed  the 
normal  range  in  certain  directions,  and  encounter  a  spring-like  insur- 
mountable resistance  in  the  opposite  directions,  the  case  is  certainly 
one  of  dislocation. 

This  rule  is  subject  to  the  slight  limitation  that  there  is  some 
diminution  of  internal  rotation  on  passive  movement,  in  cases  of 
impacted  fracture  of  the  neck  of  the  femur,  and,  exceptionally,  there 
is  also  diminution  of  external  rotation. 

Finally,  we  proceed  to  palpation.  In  dislocations,  the  head  of  the 
femur  can  be  felt  in  an  abnormal  position,  and  in  fractures,  we  can 
recognize  thickening  of  the  trochanteric  mass  and  strikingly  abnormal 
protuberance  of  bone.  The  examination  of  active  and  passive  move- 
ments, and  the  palpation  afford  the  opportunity  of  noting  the  degree 
and  the  localization  of  the  pain. 

We  have  now  arrived  at  the  stage  wherein  we  may  apply  the 
results  of  our  examination  to  the  formation  of  a  diagnosis. 


DISLOCATIONS   AND    FRACTURES   OF   THE    HIP  615 

^.—DIAGNOSIS  OF  THE  VARIOUS  FORMS  OF  INJURY. 
(1)  DISLOCATIONS. 

Having  diagnosed  a  dislocation,  it  remains  to  determine  its 
variety  : — 

(a)  If  the  thigh  is  rotated  inwards,  a  simple  mechanical  con- 
sideration will  show  that  the  head  of  the  femur  must  have  gone 
backwards,  and  therefore  the  case  is  one  of  posterior  dislocation.  In 
ordinary  dislocations  the  Y-shaped  ligament  is  not  ruptured,  and  this 
structure  maintains  the  thigh  in  the  position  of  flexion  and  adduction. 
If  the  three  characteristic  anomalies  of  posture — internal  rotation, 
adduction  and  flexion — are  not  very  pronounced,  we  may  conclude 
tliat  the  head  of  the  femur  has  escaped  in  an  upward  direction, 
towards  the  iliac  fossa  (fig.  356)  iliac  dislocation.  If,  however,  the 
abnormal  posture  is  very  pronounced  we  assume  that  the  head  has 
escaped  in  a  backward  and  downward  direction — a  sciatic  dislocation 
(fig.  357).  In  the  former  case,  the  rent  in  the  capsule  is  at  the  back 
and  above,  in  the  latter  case  it  is  at  the  back,  or  behind  and  below. 
VVe  may  summarize  the  differences  into  a  definite  law  as  follows  : 
An  iliac  dislocation  exists  if  the  patient,  on  lying  down,  is  able  to  conceal 
the  flexion  by  means  of  compensating  lordosis  of  tlie  Inmbar  spine,  and 
bring  his  two  legs  into  an  approximately  parallel  position,  and  if  on 
standing  up,  he  is  able  to  tonch  the  ground  with  Jiis  toes.  On  the  other 
hand,  a  sciatic  dislocation  is  present,  if  the  most  extreme  lumbar  lordosis 
is  unable  to  abolish  the  flexion,  if  the  patient,  on  lying  down,  places  the 
tliigli  of  the  dislocated  leg  on  the  healtJiy  thigh,  and  if  he  is  unable  to 
toucli  tlie  ground  with  his  toes  on  standing  up. 

It  sometimes  happens  that  our  examination  points  to  an  iliac 
dislocation,  but  we  are  told  that  the  abnormality  of  position  was 
much  more  striking  immediately  after  the  accident,  and  that  the  limb 
has  gradually  returned  to  a  more  normal  position,  either  spontaneouslv 
or  after  unsuccessful  attempts  at  reduction  by  the  friends  of  the  injured 
person  or  by  a  quack.  We  must  not  treat  such  information  lightly, 
but  must  rather  conclude  therefrom  that  the  dislocation  was  originally 
of  the  sciatic  variety  with  a  rent  in  the  capsule,  behind  and  below,  but 
that  as  a  result  of  the  weight  of  the  limb  or  of  the  attempts  at  reduc- 
tion, the  hf-ad  of  the  femur  has  glided  upwards  and  reached  the 
position  of  an  iliac  dislocation.  This  conclusion  is  very  important 
from  the  point  of  view  of  eft'ecting  complete  reduction. 

It  is  absolutely  impossible  to  mistake  posterior  dislocation  for  any 
other  injury  of  the  hip.  Impacted  fractures  of  the  neck  of  the  femur 
with  internal  rotation  do  certainly  occur,  but  very  rarely.  But  in 
such  cases  the  freedom  of  abduction  and  the  absence  of  the  head 
of  the  bone  from  an  abnormal  situation  show  that  no  dislocation 
exists. 


6i6 


SURGICAL   DISEASES   OF   THE   EXTREMITIES 


The  similarity  of  this  unusual  form  of  impacted  adduction  fracture 
to  posterior  dislocation  may  be  very  close  indeed,  and  I  have  seen  an 
example  of  this  in  the  wards  of  a  colleague.  In  this  case,  the  idea  of 
dislocation  was  only  dispelled  by  the  absence  of  the  head  of  the  bone 
from  an  abnormal  position,  and  by  the  skiagram. 


)^ 


L 


Fig.  356. — Iliac  dislocation. 


Fig.  357a. — Sciatic  dislocation. 


If  a  posterior  dislocation  is  coniplicated  by  other  injuries,  greater 
difficulties  of  diagnosis  occur.  If  the  injury  has  resulted  from  some 
great  violence,  the  Y-shaped  ligament  may  occasionally  be  torn  and 
then  a  regular  dislocation  be  converted  into  an  irregular  one.  The 
limitations  of  movement  which  ordinarily  iiidicate  a  dislocation,  would 
not  be  present  in  such  a  case,  but,  on  the  other  hand,  the  head  of  the 
femur  would  be  more  accessible  to  palpation  and  thus  afford  evidence 


DISLOCATIONS    AND    FRACTURES    OF   THE    HIP 


617 


of  the  dislocation.  In  some  typical  cases  of  posterior  dislocation, 
grating  and  crepitus  are  heard,  which  lead  to  errors  in  diagnosis  and 
suggest  fracture  of  the  neck  of  the  femur.  As  a  matter  of  fact,  a 
portion  of  the   margin   of  tJie  acctahiilniii   has   been   torn  oft   in   these 


Fig.  3S7iJ. — Sciatic  dislocation. 

cases.  If  the  piece  of  acetabulum  broken  off  is  large,  the  displaced 
head  will  not  be  retained  in  any  of  the  typical  positions  of  dislocation. 
In  such  a  case  the  diagnosis  from  subcapital  fracture  can  only  be 
made  by  means  of  a  skiagram.  A.  combination  of  dislocation  with 
fractnre  of  tlic  nccl^  of  the  femnr  is 
very  difficult  to  diagnose,  because 
it  presents  a  very  unusual  picture. 
The  diagnosis  can  only  be  arrived 
at  by  demonstrating  that  the  head 
of  the  bone  does  not  follow  the 
limb  on  rotation,  and  that  it  is  in 
an  abnormal  position. 

(6)  If  there  is  limitation  of  move- 
ment indicating  dislocation,  and 
the  limb  is  turned  ontwards,  we 
must  conclude  that  the  head  of  the 
bone  has  escaped  fonvards,  and  that, 
therefore,  an  anterior  dislocation 
exists.  We  have  already  seen  that 
the  approximation  of  the  trochanter 
to  the  middle  line  is  another  indica- 
tion of  this  injury.  As  the  Y-shaped 
ligament  remains  intact  a  more  or 
less  considerable  abduction  results. 
If  this  abduction  is  not  very  pro- 
nounced, and  the  injured  limb  can 

be  placed  parallel  to  the  sound  one,  and  is  also  in  a  position  of  exten- 
sion, the  dislocation  is  forwards  and  nficards.  It  is  termed  ilio- 
pectinal    dislocation   or    pubic  dislocation    in    accordance  with    the 


Fig.   358. — Portion    of  upper   margin  of 
acetabulum  detached. 


8l8  SURGICAL   DISEASES   OF   THE   EXTREMITIES 

situation  in  which  the  head  of  the  bone  is  found  (fig.  359).  The  fact 
that  the  head  of  the  bone  can  be  felt  on  the  horizontal  ramus  of  the 
pubis  in  the  inguinal  region  furnishes  a  clinching  demonstration 
of  the  accuracy  of   the    diagnosis.      The  slight  abduction   gives  the 


Fig.  359. — Ilio-pectineal  dislocation. 


Fig.  360. — Inter-trochanteric  fracture. 


hmb  the  appearance  of  some  lengthening,  and  when  the  sound  limb  is 
adducted  close  to  the  injured  one  the  sound  limb  looks  shortened  and 
the  injured  limb  lengthened.  If  both  limbs  are,  how^ever,  measured 
in  the  same  position,  some  shortening  of  the  distance  between  the 
anterior  superior  spine  and  the  malleolus  will  always  be  found. 


DISLOCATIOXS   AND    FRACTURES    OF   THE    HIP 


619 


In  this  dislocation  the  femoral  artery  can  be  felt  internal  to  the 
head  of  the  femur,  and,  indeed,  the  artery  may  be  lifted  up  by  it. 
Neuralgic  pains  and  disturbances  of  sensation  ui  the  area  of  the 
anterior  crural  nerve   indicate  that  this  nerve   has  been  injured. 

If  the  abduction  is  much  more  definitely  pronounced,  and  is 
associated  with  flexion,  and  the  head  of  the  bone  is  not  found  on 
the  horizontal  ramus  of  the  pubis,  we  make  the  diagnosis  of 
obturator  dislocation.  In  well-developed  muscular  persons  the 
head  of  the  bone  cannot  easily  be  felt.  In  confirmation  thereof 
the  region  of  the  trochanter  will  not  only  be  flattened  out,  as  in 
suprapubic  dislocation,  but  will  also  be  drawn  in.  Finally,  we  shall 
infer,  from  radiating  pains  and  parassthesia  on  the  inner  side  of  the 
thigh,  that  the  obturator  nerve  has  been  compressed. 


"S-J^ 


Fig.  ^61. — Obturator  dislocation. 


If  a  case  presents,  with  outward  rotation,  an  increase  of  the  flexion 
to  a  right  angle,  we  may  diagnose  the  very  rare  dislocation  towards 
the  perinaeum,  i.e.,  perineal  dislocation. 

We  may  now  consider  what  mistakes  may  arise  in  connection 
with  anterior  dislocations.  Supposing  the  external  rotation  in  a  case 
of  suprapubic  dislocation  would,  for  a  moment,  suggest  fracture 
of  the  neck  of  the  femur  [cf.  figs.  359  and  360),  the  presence  of 
the  head  of  the  bone  in  an  abnormal  position  should  at  once 
establish  the  diagnosis  of  dislocation  with  so  much  certainty  that 
no  other  differential  signs  would  be  required.  Obturator  dislocation 
is  distinguished  from  fracture  of  the  neck  of  the  femur  by  abduc-. 
tion  of  the  limb,  by  considerable  flexion,  and  also  by  indrawing  of 
the  trochanter  region  (fig.  361).  This  last  sign  is  only  equally. 
40 


620 


SURGICAL   DISEASES   OF  THE    EXTREMITIES 


pronounced  in  fracture  of  the  pelvis  when  the  head  of  the  femur  is 
driven  into  the  pelvic  cavity — the  so-called  central  dislocation. 

Perineal  dislocation,  with  the  very  unusual  posture  arising  there- 
from, cannot  be  mistaken  for  any  fracture. 

C(0   It  is   necessary  to   mention   finally  the  very  rare  dislocations, 
upwards  and  downivards. 


Fig.  362. — Obturator  dislocation. 

Supracotyloid  dislocation  resembles  a  suprapubic  dislocation, 
forwards  and  upwards,  except  that  the  head  of  the  bone  is  felt 
immediately  below  the  anterior  superior  spine.  This  form  is  easily 
recognized.  Infracotyloid  dislocation,  i.e.,  downward  dislocation,  is 
recognized  by  the  flexion  of  the  thigh  to  a  right  angle,  with  slight 
external  rotation  and  abduction.  It  approximates  in  signs  to  an 
obturator  dislocation. 


DISLOCATIONS   AND    FRACTURES   OF   THE    HIP  62 1 

(2)  CONTUSIONS,    SPRAINS,    FRACTURES. 

If  the  passive  movements  in  the  foregoing  examination  have  been 
free,  and  therefore  the  possibihty  of  dislocation  is  excluded,  we  have 
to  decide  between  contusion,  sprain  and  fracture. 

Some  indications  will  already  have  been  furnished  by  the  cause. 
A  contusion  arises  from  a  direct  injury  to  the  hip.  But,  in  the 
absence  of  such  a  cause,  a  sprain  is  the  most  likely  diagnosis, 
as,  for  instance,  when  an  elderly  man  collapses  after  an  excessive 
movement  of  external  rotation.  This  injury  would  not,  however, 
completely  abolish  the  supporting  function  of  the  limb.  If  the  patient 
makes  fruitless  attempts  to  stand  and  to  walk,  and  finally  allows 
himself  to  be  carried  home  and  put  to  bed,  we  may  assume  the 
presence  of  a  fracture.  But  if  he  walks  home  on  foot,  the  case  is 
either  one  of  contusion  or  sprain,  in  accordance  with  the  form  of  the 
injury. 

There  is,  however,  one  important  exception  to  this  rule,  which  not 
so  much  concerns  the  fact  that  sometimes  contusions  and  sprains 
cause  very  grave  disturbances  of  function,  as  that  certain  fractures 
are  attended  by  very  little  derangement.  It  happens,  especially  in  the 
case  of  impacted  fractures,  and  even  in  separation  of  the  epiphyses  in 
young  people,  that  the  patient  is  often  able  to  walk  home.  Jf  the 
practitioner  relies  upon  this  circumstance  to  exclude  a  fracture, 
and  neglects  a  more  careful  examination,  both  he  and  the  patient  may 
be  confronted,  in  the  course  of  a  few  weeks,  with  the  unpleasant 
surprise  of  a  healed  fracture,  with  shortening  and  external  rotation, 
i.e.,  a  irainuatic  coxa  vara  ;  unless  the  fracture  has,  in  the  meantime, 
been  diagnosed  by  another  practitioner. 

If  the  patient  lies  extended  on  his  bed,  the  position  of  the  limb 
affords  certain  indications.  A  normal  position  is  in  favour  of  a 
simple  contusion,  as  most  fractures  of  the  neck  of  the  femur  are 
associated  with  external  rotation. 

We  have  already  mentioned  the  rare  cases  of  impaction  in  internal 
rotation.  This  possibility  must  always  be  thought  of,  lest  a  disloca- 
tion be  wrongly  diagnosed. 

If  it  is  impossible  to  raise  the  extended  limb,  we  must  assume  the 
presence  of  a  fracture,  as  previously  stated. 

We  must  also  consider  the  amount  of  spontaneous  pain  and  the 
painfulness  of  the  joint,  when  it  is  interfered  with.  As  Kocher  points 
out,  the  spontaneous  pain  in  contusion  may  be  disproportionately 
great,  despite  slight  loss  of  power,  whereas  in  fracture  it  may  be  very 
slight,  despite  complete  loss  of  power.  On  the  other  liand,  the  pain 
caused  by  pressure  exerted  in  the  axis  of  the  femur  is  slight  or  com- 
pletely absent  in  contusion,  whereas  it  is  always  present  in  cases  of 
recent  fracture.     Thus  we  arrive  at  the  following  rule  : — 

If  a  person  suffers  a  severe  loss  of  poiver  in  consequence  of  a  direct  or 


622  SURGICAL    DISEASES    OF   THE    EXTREMITIES 

indirect,  seemingly  insignificant  injurx  to  tJie  hip,  a  fracture  is  highly 
probable.  Tlie  greater  tJic  contrast  betiveen  spontaneous  pain  and  the 
extent  of  functional  disturbance,  the  more  likely  it  is  that  a  fracture  has 
taken  place.  If  the  supporting  function  of  tJie  limb  is  abolished,  although 
the  spontaneous  pain  is  only  slight,  there  is  certainly  a  fracture  present. 

In  the-e  circumstances,  there  is  no  difficulty  in  bringing  forward 
direct  evidence  of  the  fracture.  It  is  certain  that  a  complete  fracture 
exists  if  there  is  shortening  which  cannot  be  attributed  to  a  previous 
injury,  or  if  the  trochanter  is  above  its  normal  position,  or  if  there  is 
an  approximation  of  the  femur  to  the  pelvis. 

Partial  fractures  of  the  trochanter,  detachments  or  abrasions  of 
small  pieces  thereof,  can  onlv  be  distinguished  from  smiple  sprains  by 
means  of  a  skiagram,  because  of  the  great  effusion  of  blood  into  the 
soft  parts. 

Complete  detachment  of  the  great  trochanter,  which  is  rare,  mav  be 
diagnosed  bv  the  loss  of  power  of  support  in  the  hip,  despite  the 
normal  condition  of  the  joint,  and  by  the  demonstration  on  palpation 
of  the  upwardly  displaced  fragment. 

DetacJinieut  of  tlie  small  troclianter,  which  is  still  more  rare,  mav 
be  recognized,  according  to  Ludlofif,  by  the  fact  that  the  patient  cannot 
raise  his  limb  when  in  a  sitting  posture. 

We  must  not  base  the  diagnosis  of  a  bone  lesion  merely  on  the 
presence  of  crepitus.  There  are  cases  in  which,  independently  of  any 
injury,  the  anterior  margin  of  the  tendon  of  the  gluteus  maximus,  or 
the  ileo-tibial  band  of  the  fascia  lata,  glides  over  the  trochanter  with 
palpable  and  audible  crepitus,  when  the  muscle  contracts  powerfully. 
This  has  been  termed  in  French,  "  hanche  a  ressort,"  but  the  German 
expression,  "  scJinappeude  Hufte,"  is  more  expressive. 

Having  decided  that  a  complete  fracture  exists,  we  must  next 
determine  where  it  is  situated,  and  whether  it  is  loose  or  impacted. 
We  cannot  relv  on  skiagraphy,  even  as  much  as  in  elbow  or  shoulder 
cases,  because  the  conveyance  of  a  patient  with  an  injured  hip  to  an 
X-ray  institute  is  mostely  quite  impracticable.  But,  nevertheless,  a 
correct  diagnosis  is  most  important  for  prognosis  and  treatment. 

We  may  here  briefly  review  the  various  forms  of  fracture.  It  was 
formerly  the  custom  to  distinguish  between  intracapsular  and  extra- 
capsular fractures.  But  as  the  capsule  extends  farther  towards  the 
trochanteric  region  on  the  anterior  surface  than  it  does  on  the 
posterior  surface,  and  as  also  the  line  of  fracture  is  often  irregular,  it 
follows  that  numerous  fractures  of  the  neck  of  the  femur  are  of  a 
mixed  variety,  partially  extra-  and  partially  intra-capsular.  We, 
therefore,  adopt  Kocher's  classification  and  divide  these  fractures 
according  to  their  position,  regardless  of  their  relations  to  the  capsule. 

One  line  of  fracture  (fig  363,  i)  lies  at  the  border  between  the 
head  and  the  neck.  This  variety  is  termed  by  Kocher,  fractnra 
subcapitalis,  and  if  pure,  is  always  intracapsular.  Another  line  of 
fracture  lies  along  the  neck  itself,  where  it  merges  with  the  tro- 
chanter mass,  that  is  to  say  in  the  region  of  the  intertrochanteric  line 


DISLOCATIOXS   AXD    FRACTURES    OF   THE    HIP 


623 


(fig.  363,  2) — fractiira  intciirocliaiitcrica.  This  fracture  is  partially 
intra-  and  partially  extra-capsular.  The  pcrtrochanteyic  fracture,  the  line 
of  which  traverses  the  trochanter  mass,  lies  close  to  the  line  of  the 
fracture  of  the  neck  of  the  femur.  It  generally  runs  obliquely,  from 
outwaids  and  upwards  in  front,  to  downwards  and  inwards  behind 
(fig.  363,  3)  ;  this  fracture  is  more  common  than  the  pure  intertro- 
chanteric variety.  The  subtrochanteric  fracture,  which  traverses  the 
bone  below  the  lesser  trochanter,  belongs  to  the  fractures  of  the  shaft, 
but  it  is  more  practical  to  discuss  it  with  the  fractures  of  the  neck  of 
the  femur  (fig.  303,  4  and  5). 

Intertrochanteric  and  pertrochanteric  fractures  are  not  usually  pure 
in  form.  The  former  is  verv  often  associated  with  a  fracture  in  the 
trochanter  mass — mdeed  recent  autopsies  show  that  this  is  probably 


r  'i,x 


Fig    363.— a— Z',  Typical  lines  of  direction  of  fractures  at  the  neck  of  the  femur. 
a  h 

1.  Fractura  subcapitalis.      _  6.  Y-shaped  fracture. 

2.  ,,         intertrochanterica. 

3.  ,,         pertrochanterica. 

4.  ,,         subtrochanterica  (oblique  variety). 

Rotation  fracture. 

5.  .,         Ditto  (transverse  variety). 

the  rule — so  that  really  a  Y-shaped  fracture  results  (fig.  363,  6).  Per- 
trochanteric fractures  may  also  be  combined  with  intertrochanteric, 
as  well  as  with  subtrochanteric  fractures. 

Impaction  may  occur  in  all  forms,  except  in  a  pure  subtrochanteric 
fracture. 

How  much  of  this  can  be  recognized  with  certainty  in  the  living 
subject  without  X-rays  ? 

{a)  In  the  first  place  we  must  decide  whether  a  pertrochanteric 
or  subtrochanteric  fracture  is  present  or  not.     As  the  line  of  fracture 


624 


SURGICAL   DISEASES    OF   THE    EXTREMITIES 


in  both  of  these  varieties  is  below  the  insertion  of  the  internal 
rotators,  the  Hmb  lies  in  a  position  of  complete  external  rotation 
(fig.  365)  because  of  its  own  weight.  It  is  quite  impossible  for  the 
patient  to  effect  the  slightest  internal  rotation.  If  we  turn  the  leg 
inwards,  it  falls  limp  on  to  its  outer  side  as  soon  as  we  leave  go,  in 
contrast  to   fractures    seated   higher  up,   in   which  the  limb  retains  a 


Fig.  364. — Interlrochanteric  fracture.     Incomplete  external  rotation.     Shortening. 

certain  amount  of  power  in  the  absence  of  impaction,  because  of  the 
muscles  inserted  into  the  trochanter  (fig.  364). 

In  pertrochanteric  fractures,  high  up,  the  limb  alwavs  possesses  a 
certain  amount  of  power. 

The  measurements  of  the  limb  and  the  condition  of  the  trochanter 
are    decisive.       If   there   be  shortening  of   the    distance  between   the 


Fig.  365. — Subtrochanteric  fracture.     Complete  external  rotation.     Shortening. 

anterior  superior  spme  and  the  malleolus,  and  of  the  distance  between 
the  trochanter  and  the  malleolus,  with  the  trochanter  in  a  normal 
position,  the  fracture  must  be  below  the  trochanter.  If,  on  the  other 
hand,  only  the  distance  between  the  anterior  superior  spine  and 
malleolus  is  shortened,  and  the  trochanter  is  abnormally  high  in  posi- 
tion, the  fracture  cannot   be  below  the   trochanter  (see  fig.  355).     If 


DISLOCATIONS   AND    FRACTURES    OF   THE    HIP  625 

the  intense  swelling  of  the  soft  parts  or  some  old  shortening  render 
the  results  of  measurement  indecisive,  the  case  may  be  elucidated  by 
the  behaviour  of  the  trochanter  on  rotation  of  the  thigh.  If  the  tip 
of  the  trochanter  revolves  with  the  rotation,  the  fracture  is  above  it  ; 
if  it  does  not  revolve,  the  fracture  is  below  it.  An  impacted  pertro- 
chanteric fracture  is  often  recognizable  by  the  presence  of  a  double 
prominence  instead  of  the  great  trochanter,  further  by  the  tenderness 
over  the  trochanter  itself,  even  when  the  pressure  is  made  externally, 
and  often  by  the  involvement  of  the  thigh  in  the  swelling. 

If  the  fracture  is  below  the  tip  of  the  trochanter  it  may  either  be 
pertrochanteric  or  subtrochanteric.  In  the  latter  case  the  whole 
trochanter  mass  remains  unmoved  on  attempting  rotation  ;  in  the 
former  case,  the  tip  of  the  trochanter  does  not  ioWow  the  movement 
of  rotation,  but  the  trochanter  mass,  grasped  lower  down,  will  be  felt 
to  turn  with  the  lower  fragment.  Fracture  through  the  trochanter  is 
also  recognized  by  definite  broadening  of  tins  structure,  and  by  very 
pronounced  pain  on  pressure  in  its  vicinity.  In  fractures  below  the 
trochanter  there  is  no  broadening  of  this  structure,  and  the  maximum 
swelling  is  below  it. 

In  a  typical  pertrochanteric  fracture,  wherein  the  plane  of  the 
fracture  runs  from  the  front  downwards  and  backwards,  it  is  very 
often  possible  to  feel  the  sharp  edge  of  the  lower  fragment,  which 
is  displaced  upwards  and  forwards,  as  Kocher  has  pointed  out.  On 
the  other  hand,  in  a  pure  subtrochanteric  transverse  fracture,  the  lower 
end  of  the  upper  fragment,  which  is  kept  flexed  by  the  ileo-psoas,  can 
be  felt  beneath  the  muscles. 

(6)  If  we  have  excluded  both  a  per-  and  sub-trochanteric  fracture, 
and  therefore  limited  the  diagnosis  to  fracture  of  the  neck  of  the 
femur,  we  still  have  to  distinguish  between  a  subcapital  and  inter- 
trochanteric fracture,  and  also  to  decide  whether  it  is  impacted  or 
nou-inipacted. 

We  first  endeavour  to  localize  the  seat  of  maximum  pain,  on 
pressure.  If  it  is  beneath  the  middle  of  Poupart's  ligament  in  the 
neighbourhood  of  the  head  of  the  femur,  we  may  conclude  that  the 
fracture  is  subcapital.  If  the  site  of  maximum  pain  on  pressure  is 
in  the  proximity  of  the  trochanter  mass,  we  may  assume  that  the 
fracture  is  intertrochanteric.  At  the  same  time,  we  notice  whether 
there  is  any  marked  sivdling.  If  there  be  any  in  the  neighbourhood 
of  the  trochanter  mass  it  is  clear  that  an  intertrochanteric  fracture 
must  be  present.  If,  on  the  other  hand,  the  trochanter  region  can  be 
freely  grasped,  the  fracture  must  either  be  subcapital  or  an  inter- 
mediate form. 

In  order  to  examine  the  trochanter  for  pain  on  pressure  and  for 
change  in  shape,  we  press  with  the  tips  of  the  second,  third  and 
fourth  fingers  in  the  groove  behind  the  trochanter  and  make  counter- 
pressure  with  the  thumb  in  front  of  it. 


626  SURGICAL   DISEASES    OF   THE    EXTREMITIES 

We  may  also  derive  important  information  by  exaniiuing  the  inovc- 
ments.  If  crepitus  is  felt,  impaction  is  excluded.  It  is  also  excluded 
if  the  thigh  can  be  moved  backwards  and  forwards  on  the  pelvis — 
obviously  without  using  force  (the  va  et  vient  movement  of  French 
authors). 

If  we  find  on  rotating  the  limb  that  the  tip  of  the  trochanter  turns 
on  its  own  axis  and  does  not  describe  any  definite  curve,  a  loose  inter- 
trochanteric fracture  must  be  present. 

If  the  trochanter  describes  a  definite  curve  when  the  limb  is  rotated 
— a  curve  which  is  always  smaller  than  normal  in  the  case  of  fractures 
— there  are  two  possibilities  present.  If  the  signs  previously  mentioned 
enable  us  to  exclude  impaction,  the  neck  of  the  femur,  which  repre- 
sents the  radius  of  the  curve  described  by  the  trochanter,  must  still  be 
attached  to  it.  In  other  words,  a  non-impacted  subcapital  fracture  is 
certainly  present.  If,  on  the  other  hand,  we  must  assume  that  there  is 
impaction,  we  can  only  suspect  the  exact  situation  of  the  fracture  by 
localizing  the  direct  pain  on  pressure  and  the  thickening  of  the  bone. 

If  there  is  too  much  swelling  to  permit  of  this,  it  does  not  prejudice 
the  question  of  treatment.  Every  impacted  fracture  which  is  suspicious 
of  a  subcapital  fracture  must  be  handled  with  due  attention  to  the 
impaction,  because  this  offers  the  safest  guarantee  for  bony  union.  It 
is  better  to  do  without  a  definite  diagnosis  than  to  disengage  the 
impaction.  Only  an  X-ray  examination  can  define  the  line  of  fracture 
and  enable  us  to  disengage  the  impaction,  when  the  fracture  is 
not  directly  at  the  head,  and  the  eversion  of  the  limb  renders  it  desir- 
able to  improve  its  position. 

In  some  cases  the  etiology  assists  in  the  forming  of  a  diagnosis, 
but  very  often  the  patient  himself  does  not  know  the  details  of  the 
accident,  and  his  statements  are  quite  indefinite  and  useless.  If  he  has 
fallen  on  his  feet  and  the  blow  has  thus  been  imparted  from  below,  a 
subcapital  fracture  is  the  most  likely  result.  A  fall  on  the  region  of 
the  trochanter  is  the  most  frequent  cause  of  intertrochanteric  fracture. 
Extreme  external  rotation  is  just  as  likely  to  be  due  to  pertrochanteric 
or  to  subtrochanteric  fracture  as  to  subcapital  fracture,  but  does  not 
suggest  intertrochanteric  fracture. 

So  far  we  have  purposely  not  laid  any  stress  on  the  age  of  the 
patient.  Too  much  importance  has  hitherto  been  attached  to  the 
statement  that  fracture  of  the  neck  of  the  femur  is  the  prerogative  of 
old  people.  There  is  no  doubt  that  old  age  predisposes  to  it,  but 
fracture  of  the  neck  of  the  femur  is  by  no  means  a  rarity  in  young 
persons. 

The  patients,  after  a  slight  injury,  remain  in  bed  for  a  few  days, 
sometimes  even  for  two  or  three  weeks,  with  the  diagnosis  of  contusion 
of  the  hip,  or  with  no  diagnosis  at  all,  and  then  begin  to  resume  their 
occupation.  After  a  few  months  have  elapsed,  they  consult  their 
doctor  because  of  pains  in  the  hip  and  slight  lameness.  Examination 
then  reveals  a  shortening  of  i  to  2  cm.,  a  corresponding  elevation  of 
the  level  of  the  trochanter,  diminution  of  the  power  of  abduction  and 


DISLOCATIOxNS   AND    FRACTURES    OF   THE    HIP 


627 


possibly  some  slight  external  rotation.  This,  of  course,  establishes  the 
diagnosis  of  coxa  vara,  and  a  careful  investigation  of  the  history  may 
be  required  in  order  to  detect  the  traumatic  origin  of  the  malady. 

It  may  be  quite  impossible  to  distinguish  between  traumatic  and 
spontaneous  coxa  vara,  and  even  a  skiagram  may  not  always  enable 
us  to  come  to  a  conclusion,  as  illustrated  in  fig.  384  a. 

I  remember  one  occasion  on  which  two  surgeons  who  had  had 
considerable  experience  of  this  condition  were  unable  to  agree,  even 
when  the  head  of  the  bone  had  been  excised.  The  bending  does 
not  usually  take  place  in  the  middle  of  the  neck  of  the  femur  in 
the  qoxa    vara  of  young  people, 

but  in  the  neighbourhood  of  the      ■ 1 

epiphyseal  line,  which  is  also  the 
most  frequent  site  of  fractures. 
The  matter  is  of  importance  in 
regard  to  accident  insurance.  As 
far  as  our  present  experience  goes, 
it  would  appear  that  the  accident 
should  always  be  held  respon- 
sible, if  an  injury  has  really  beeri 
proved,  and  if  no  hip  symptoms 
■existed  previously.  The  other  hip 
should  always  be  examined  and 
a  skiagram  made.  If  it  shows 
signs  of  commencing  coxa  vara 
Ihe  accident  can  only  be  credited 
as  an  aggravating  factor. 

Much  controversy^  has  raged 
as  to  whether  fractures  during  the 
period  of  growth  are  separa- 
tions of  the  epiphysis  or  not. 
But  this  is  mainly  a  quibble 
about  words.  If  the  fracture  is 
situated  close  to  the  trochanter 
mass,  as  actually  occurs,  the  case 
is  simply  one  of  the  ordinary 
intertrochanteric  fracture.  The  question  can  only  concern  subcapital 
fracture,  where  the  epiphyseal  line  always  constitutes  a  locus  minoris 
resistentiae.  This  does  not,  however,  mean  that  the  whole  extent  of 
the  line  of  fracture  must  follow  the  epiphyseal  line.  It  may  deviate 
from  this  line  either  towards  the  head  or  towards  the  neck,  just 
as  happens  with  fractures  close  to  other  epiphvseal  lines.  It  is  quite 
immaterial  from  the  point  of  view  of  treatment  whether  these  cases 
are  legarded  as  separations  of  epiphyses  or  as  fractures.  There  is 
only  one  differentiating  sign,  but  this  must  be  appealed  to  with 
caution.     If  we  only  feel  soft  crepitus  we  may  assume  that  the  line 


Fig.  366. — Separalion  of  epiphysis  in  a  girl 
aged  14. 


628 


SURGICAL   DISEASES    OP^   THE    EXTREMITIES 


of  fracture  runs  along  the  cartilage,  but  the  rougher  the  crepitus  is 
the  more  the  fracture  will  have  involved  the  bone. 

Can  a  fracture  of  the  neck  of  the  femur  be  mistaken  for  any  other 
injury,  apart  from  dislocation,  contusion,  and  sprain,  which  have 
already  been  referred  to  ? 

Fractures  of  the  shaft  of  the  femur  do  not  come  into  serious 
consideration,  because  the  seat  of  the  injury  is  verv  clearly  evident 
on  palpation  and  on  testing  for  abnormal  mobility.  But,  on  the 
other  hand,  in  very  severe  injuries,  such  as  those  sustained  in  the 
collapse  of  a   building,  a  fracture  of  the   neck  of  the  femur  may  be 


Fig.  367. — Subcapital  fracture. 


Fig.  368. — Intertrochanteric  fracture. 


associated  with  fracture  of  the  shaft,  and  the  diagnosis  thus  be 
rendered  diiScult. 

It  is,  however,  quite  conceivable  that  a  fracture  of  the  pelvis 
may  be  mistaken    for  a   fracture  of  the  neck  of   the   femur. 

If  there  is  a  striking  limitation  of  active  movements,  especiallv 
of  flexion,  although  the  measurements  and  the  passive  mobilitv  are 
normal,  we  should  think  of  a  fracture  of  tlie  ring  of  the  pelvis, 
unaccompanied  by  displacement.  This  would  be  confirmed  by  pain  on 
pressure  on  the  pelvic  fossa,  by  pressing  the  two  pubic  bones  away 
from  one  another,  and  by  force  applied  in  the  axis  of  the  femur.     We 


DISLOCATIONS    AND    FRACTURES    OF   THE    HIP 


629 


should  endeavour  to  determine  the  exact  course  of  the  fracture 
by  palpatmg  the  accessible  portions  of  the  pelvis,  more  especially 
the  iliac  crest,  the  pubis  (both  mternally  and  externally),  and  the 
sacrum. 

If,  in  addition  to  the  loss  of  power  just  described,  there  is  also 
shortening,  which  is  evident  to  the  eye,  but  which  cannot  be  demon- 
strated by  the  tape  measure,  we  must  conclude  that  the  entire  por- 
tion of  the  pelvis,  embracing  the  acetabulum  and  the  anterior  superior 
spine,  has  been  separated  from  its  connections  through  a  double  frac- 
iurc  of  the  pelvic  ring,  and  has  been  at  the  same  time  displaced  upwards 


Fig.  369.- — Pertrochanteric  fracture. 


Fig.  370. — Subtrochanteric  fracture. 


(double  vertical  fracture  of  Alalgaigne).  The  limb  is  usually  everted 
in  these  cases,  just  as  in  a  fracture  of  the  femur. 

The  limb  may  appear  to  be  lengthened,  although  the  measure- 
ments are  normal,  in  cases  wherein  the  one  half  of  the  pelvis  is  dis- 
placed downwards  in  relation  to  the  other  half,  as  a  result  of  a 
complete  fracture  of  the  pubis  and  a  simultaneous  loosening  of  the 
sacro-iliac  articulation. 

If  the  distance  between  the  anterior  superior  spine  and  the  mal- 
leolus is  lengthened,  without  simultaneous  lengthening  of  the  distance 
between  the  trochanter  and  the  malleolus,  and  without  evident 
lengthening  of  the  whole  limb,  and  if  at  the  same  time  passive 
movements   are    normal,  and    the  supporting  power   is    retained,  the- 


630 


SUKGICAL   DISEASES    OF    THE    EXTREMITIES 


case  can  only  be  one  of  fracture  of  that  portion  of  the  pelvic  fossa 
which  includes  the  anterior  superior  spine  (Duverney's  fracture). 
Pressure  on  the  pelvic  fossa  may  elicit  pronounced  pain,  and  pos- 
sibly crepitus  in  confirmation  of  this  assumption.  There  is  no 
pain  on  pressure  in  the  axis  of  the  femur. 

If  the  limb  is  shortened  and  fixed  in  a  position  of  eversion,  but  the 
head  of  the  bone  cannot  be  felt  to  be  displaced  forwards  as  in  an 
ileo-pubic  dislocation,  the  acetabulum  must  be  shattered,  and  the 
head  of  the  bone  driven  into  the  pelvis.  Rectal  examination  will 
confirm  this  diagnosis  of  central  dislocation,  which  is  a  very  rare 
injury. 

If  the  hip-joint  is  quite  free,  but  pain  is  caused  in  the  sacro-iliac 
nrticiilation  by  pressure  or  traction,  the  cause  must  either  be  a  sprain- 
ox:  a  fissnre  in  the  vicinity  of  the  articulation.  If  nothing  can  be 
detected  on  palpation,  the  diagnosis  must  be  made  bv  means  of  the 
X-rays. 

In  all  cases  of  pelvic  fracture  attention  must  be  paid  to  the 
condition  of  the  nrinary  tract,  for,  as  already  stated,  the  urethra  may 
be  injured  in  various  ways,  and  the  bladder  may  be  impaled  by  a 
splinter  of  bone.  It  is  sometimes  the  urinary  symptoms  which  draw 
attention  to  an  overlooked  fracture  of  the  pelvis. 

The  following  table  will  enable  the  beginner  to  appreciate  the 
■symptomology  of  injuries  to  the  hip  with  greater  facilitv  : — 


Active  and  passive 
movements  free  in 
all  dTections,  but 
partially  painful ; 
power  of  support 
retained  ;  no  short- 
ening 


Active  and  passive 
movements  abnor- 
mally free  in  certain 
directions,  and  re- 
strained in  others;' 
power  of  support 
almost  always  lost, 
at  any  rate,  at  first 


Direct      trauma       (Ecchy- 
moses) 


Indirect  trauma 


'Limb  inverted,  adducted 
and  flexed ;  head  to  be 
felt  on  the  pelvis 


Limb    everted    and    some- 
^     wfiat  abducted 


/"Active  flexion  quite  free 

j  Active  flexion  impossible  in  the 
L     sitting  posture 

The  foot  reaches  the  ground 
on  standing  (with  the  other 
limb  extended),  or  at  least 
the  heel  of  the  other  foot 

The  foot  does  not  reach  the 
ground 

Limb  extended ;  abduction 
slight ;  head  visible  and  pal- 
pable over  the  pubic  crest 

Head  not  palpable  there 

I  Limb  semi-flexed  ;  pronounced 
I  abduction ;  head  not  dis- 
'.     tinctly  palpable. 


Contusion  (rarel3'  an  im- 
pacted fracture  with 
slight  displacement). 

Sprain. 

Detachment  of  lesser 
trochanter. 

Iliac  dislocation. 


Sciatic  dislocation. 


Ileo-pectineal  and  pubic 
dislocation. 


Central  dislocation. 
Obturator  dislocation. 


Active  movements 
entirely  lost,  or  al- 
most so ;  passive 
movements  free  in 
all  directions,  or 
somewhat  limited 
on  internal  rota- 
tion ;  shortening 
(sometimes  very 
alight) 


Level  of  trochanter  normal ;     Trochanter    mass    painful    on     Non-impacted      pertro- 


pressure  up  to  the  top, 
thickened  :  upper  end  of 
lower  fragment  often  to  be 
felt  near  tip  of  trochanter. 


chanteric  fracture. 


distance     between      ant. 

sup.    spine   and    distance 

between    trochanter   and 

malleolus   shortened    (in-, 

fratrochanteric      shorten-  ] 

ing)  ;    tip    of   trochanter     Pain  on    pressure   below    the     Subtrochanteric      frac- 

does   not  follow  on  rota-  I      trochanter  mass  ;  upper  frag-        ture. 

tion  ;      limb      completely  \^     ment  often  to  be  felt  under 

everted  the  skin  in  flexion 


XOX-TRAUMATIC    DEFORMITIES    AT    THE    HIP-JOIXT 


631 


Active  movements 
entirely  lost,  or  al- 
most so;  passive 
movements  free  in 
all  directions,  or 
somewhat  limited 
on  internal  rota- 
tion :  shortening 
(sometimes  verj^ 
slight) 


Level  of  trochanter  very 
high;  distance  between 
ant.  sup.  spine  and  mal- 
leolus shortened ;  dis- 
tance between  trochanter 
and  malleolus  normal 
(supratrochanteric  short- 
ening) ;  tip  of  trochanter 
follows  on  rotation  ;  limb 
usually  in  semi-eversion 


Slight  active  movements  pre- 
sent ;  sometimes  even  some 
power  of  support ;  no  crepi- 
tus ;  femur  not  movable  on 
pelvis  ;  trochanter  mass  and 
tip  of  trochanter  clearly  pal- 
pable, and  not  painful  on 
pressure  externally 

Trochanter  mass  widened, 
painful  on  pressure  exter- 
nally ;  two  protuberances  to 
be  felt  on  tip  of  trochanter 


Impacted  intertrochan- 
teric or  Subcapital 
fracture  (distinction 
often  impossible  clinically 
without  X-rays). 


Impacted  pertrochan- 
teric fracture,  or  mixed 
foim  with  impacted  in- 
tertrochanteric frac- 
ture. 

Free  subcapital  frac- 
ture or  separation  of 
epiphysis. 


Free     intertrochanteric 
fracture. 


Active  mobility  slight  ;  no 
power  of  support  ;  teniur 
movable  on  pelvis  with 
crepitus  ;  pain  on  pressure, 
especially  under  Poupart's 
ligament,  and  not  in  the  tro- 
chanter region ;  trochanter 
describes  a  curve  on  rotation 

Active  mobility  and  power  of 
support  nil;  femur  movable 
on  pelvis  with  crepitus  ;  pain 
on    pressure    on    inner    side 

of  trochanter  (as   felt   from  ♦ 

behind)  ;    latter  revolves  on 
1      itself  (z.«.,  in  its  long  axis) 

Distance  between  ant.  sup.  \ 

spine  and  malleolus  nor-  ^        x  ^  t   t-^ 

mal ;  passive  movements  I  Localized    pain    on    pressure     Fracture   of  great  tro- 
free;    active    movements  ("      over  great  trochanter  chanter, 

also  free,  but  some  loose-  i 
ness  of  support  on  stand- j 

'"^  Fracture  of  pelvic  ring 

,        \  I      without  displacement. 

sup.  spine  and  malleolus  r      shortening  ture. 

I     increased;  function  of  hip  J  (^Fracture  of  pelvic  fossa. 

\    normal  ' 


CHAPTER   XCIII. 

MON  TRAUMATIC  DEFORMITIES  AT  THE  HIP- 
?oTnT  (CONGENITAL  DISLOCATION  OF  THE 
HIP   AND    COXA   VARA.) 

COXA  VARA  and  congenital  dislocation  of  the  hip  appear  to  be 
two  very  different  diseases,  and  yet  they  are  sometimes  mistaken  for 
one  another.  Even  experienced  observers  are  in  doubt  m  certain 
e'^es  The  difficulty  is  easily  solved  by  a  skiagram,  but  the  apparatus 
for  this  purpose  is  not  always  available.  We  must,  therefore,  endeavour 
to  establish  the  diagnosis  without  this  aid. 

A.-CONGENITAL    DISLOCATION    OF    THE    HIP. 
In   congenital  dislocation  of  the  hip,  the  head  of  the  bone  is  no 
lon'er  in  the  acetabulum,  but  is  either  above   or  below  it.     The  first 


632 


SURGICAL   DISEASES   OF   THE    EXTREMITIES 


and  inevitable  result  of  this  change  in  position  is  a  sJiortcning  of  the 
distance  hehveen  the  anterior  superior  spine  and  tlie  nialleohis  and  an 
elevation    in   the  te-eel  of  the  trocJuinter.      The  shortening  amounts  to 

about  2  cm.  even   in  little 
children. 

The  level  of  the  tro- 
chanter can  be  estimated 
rapidly  and  reliably  in 
three  different  ways  : — 

Roser-Nelaton's  line, 
which  joins  the  tuberosity 
of  the  ischium  with  the 
anterior  superior  spine  of 
the  ilium,  is  determined 
with  the  hip  semi-flexed 
(135°).  The  trochanter 
lies  normally  in  this  line. 
If  it  is  above  this  the  level 
of  the  trochanter  is  said 
to  be  raised  (fig.  371).  A  displacement  of  ^  to  i  cm.  is  not  considered 
pathological,  as  it  comes  within  the  limits  of  error  of  measurement. 


Fig.  371. — Estimation  of  the  level  of  the  trochan- 
ter by  means  of  Roser-Nelaton's  line  in  a  case  of  coxa 
vara,  a  =  Actual  level  of  the  trochanter  (here  raised), 
/;  =  normal  level  of  the  trochanter. 


Fig.  372. — Measurement  of  Bryant's  triangle  in  case  of  unilateral  congenital  dislocation  ot 
the  hip.     Normal  side.     The  triangle  is  isosceles. 

Bryant's  triangle  is  also  employed,  and  is  constructed  in  the 
following  manner  :  The  patient  lies  flat  on  his  back  and  the  axis  of 
the  femur  is  prolonged  with  a  blue  pencil  line  above  the  trochanter. 


Fig.  373. — Same  case.     Dislocated  side.     The  triangle  is  acute  angled.     The  comparative 
measurement  of  the  horizontal  base  gives  the  amount  of  displacement. 

A  vertical  line  is  then  drawn  from  the  anterior  superior  spine  to 
this  base  line,  and  another  line  is  drawn  joining  the  iliac  spine  with 
the  tip   of   the   trochanter.      The   right-angled   triangle   so    obtained 


NON-TRAUMATIC    DEFORMITIES   AT   THE   HIP-JOINT 


6-"^ 
":)^> 


is  normally  an  isosceles  triangle,  whereas  the  base  line  formed  by 
the  prolongation  of  the  axis  of  the  femur  is  shortened,  compared  to 
the  opposite  side,  when  the  level  of  the  trochanter  is  raised  (figs. 
372  and  373). 

Shoemaker's  method  is  even   more  simple,  and  it  consists  of  pro- 
longing the  line  joining  the  trochanter  icith  anterior  superior  spine,  on  to 
the  abdomen.    This  prolonged  line  normally  meets  the  median  line  at  the 
level  of  the  umbilicus  or  above  it; 
but  when  the  level  of  the  trochan- 
ter is  raised  it  intersects  this  line 
below  the  umbilicus  (fig.  374). 

The  head  of  the  femur  does 
not  leave  the  capsule  in  cases  of 
congenital  dislocation.  The  cap- 
sule becomes  dragged  out,  in  the 
shape  of  a  pocket,  and  is  displaced 
posteriorly  with  the  head.  The 
thigh  does  not,  therefore,  assume 
the  typical,  mathematically  fixed 
position  in  relation  to  the  pelvis 
which  it  presents  in  cases  of 
traumatic  dislocation.  Indeed 
the  drawn-out  capsule  permits 
abnormally  free  play  for  the  move- 
ments of  femur.  Congenital  dis- 
location of  the  hip  is  therefore 
characterized  by  remarkably  great 
acrobatic  niobilitv  of  the  thigh, 
and  there  is  no  pathognomonic 
position  in  cases  of  congenital 
dislocation  of  the  hip  in  young 
children.  Freedom  of  movement 
only  diminishes  after  the  lapse  of 
years,  but  even  then,  abnormality 
of  position  is  much  less  pro- 
nounced than  in  cases  of  trau- 
matic dislocation. 

Another  important  sign,  con- 
nected with  this  defective  fixation 
of  the  head,  is  the  possibility  of 
moving  it  backivards  and  forwards 
on  the  pelvis 

tion  of  the  hip,  if  they  are  not  too  old,  but  it  can  only  be  demon- 
strated in  refractory  children  when  the  muscles  are  relaxed  by 
anaesthesia.     Before   proceeding  to  this    test,  we  must  endeavour  to 


Fig.  374. — Same  case.  Determinalion  of 
level  of  trochanter  by  prolonging  towards 
the  umbilicus  the  line  which  joins  the  tro- 
chanter to  the  anterior  superior  spine. 


This  sign  is  never  absent  in  cases  of  congenital  disloca- 


634 


SURGICAL    DISEASES    OF   THE    EXTREMITIES 


show  that  the  licad  is  in  an  ahuoiinal  position,  and  we  shall  generally 
find  it  above  or  behind  the  acetabulum. 

In  the  case  of  thin  girls  it  is  quite  possible  to  see  the  head  of 
the  bone  moving  about,  with  every  step,  in  the  gluteal  region.  But  it 
is  not  evident  externally  in  very  small  fat  children,  nor  can  it  be 
readily  felt,  especially  if  it  is  not  fully  developed.  Sometimes  anaes- 
thesia is  indispensable  for  the  examination,  but  whether  employed  or 
not,  we  proceed  in  the  following  manner,  as  taught  by  Malgaigne 
(fig.  375).  The  child  is  laid  upon  the  healthy  side  ;  the  leg  of  the 
deformed  side  is  flexed  to  a  right  angle,  and,  if  necessary,  is  somewhat 


Fig.  375. — Palpation  of  the  head  of  the  bone  in  congenital  dislocation  of  the  hip. 

adducted.  Attempts  are  made  by  pressiu-e  on  the  femur  from  the 
knee,  with  one  hand,  to  press  the  head  of  the  bone  as  far  as  possible 
awav  from  the  pelvis.  At  the  same  time  movements  of  rotation 
are  made  with  the  same  hand,  while  the  upper  end  of  the  femur  is. 
being  palpated  by  the  other  hand.  If  only  one  protuberance  is  felt, 
this  is  the  trochanter,  and  there  is  no  dislocation  present.  But  if  kvo 
protuberances  are  felt,  one  must  be  trochanter,  and  the  other  is  the 
head  of  the  bone,  and  a  dislocation  does  exist. 

Children  who  have  alreadv  walked  for  some  time  present  another 
important  svmptom,  especially  when  the  dislocation  is  bilateral,  i.e.,  a 


NOX-TRAUMATIC   DEFORMITIES   AT   THE    HIP-JOINT 


635 


great  degree  of  lumbar  lordosis,  which  depends  upon  the  rotation  of 
the  pelvis  forwards,  upon  its  transverse  axis. 

The  dislocation  causes  the  centre  of  gravity  of  the  back  to  fall 
along  a  line  anterior  to  the  points  of  body  support,  and  the  endeavour 
to  bring  it  back  again  over  the  feet  is  the  cause  of  the  lordosis. 

The  diagnosis  of  congenital  dis- 
location of  the  hip  is  established  if 
there  is  sJiortening,  with  abnormal 
mobility  of  the  thigh,  elevated  level 


Fig.    376. — Congenital  dislocation  of 
the  hip.      (Lordosis  !) 


L__ 


Fig.  377. — Lordosis  in  progressive 
muscular  atrophy. 


of  the  trochanter  and  displaceability  of  the  femnr  on.  the  pelvis,  and  if  a 
protuberance  is  felt  besides  the  trochanter,  and  if,  in  addition  to  all  this, 
liunbar  lordosis  is  also  present. 

A  skiagram  can  only  add  a  few  details  to  the  diagnosis,  in  regard 
to  the  shape  of  the  acetabulum  and  the  head  of  the  bone. 

41 


636 


SURGICAL    DISEASES    OF    THE    EXTREMITIES 


"1 


We  have  not  vet  referred  to  the  history,  which  usually  relates  that 
nothing  was  noticed  in  the  first  year,  but  that  a  slight  lameness  was 
observed  as  soon  as  the  child  attempted  to  walk.  If  the  dislocation  is 
bilateral,  the  gait  will  be  described  as  waddling,  and  it  will  have  been 
attributed  to  weakness;  but  the  disability  will  be  said  to  be  constantly 
increasing. 

As  we  have  already  seen,  the  signs  are  so  striking,  and  can  usually 

be  demonstrated  with  so  much  ac- 
curacy that  it  is  hardly  possible  to 
overlook  a  definite  case,  and  the 
favourite  diagnosis  of  a  past  genera- 
tion— "  weakness  of  the  muscles  and 
bones  " — ought  never  to  be  made  by 
a  modern  practitioner.  An  error  in 
regard  to  a  slight  degree  of  bilateral 
dislocation  is  perhaps  excusable.  In 
such  a  case,  we  are  unable  to  judge 
of  abnormal  mobility  and  shortening 
by  comparison  with  the  healthy  side. 
We  are  only  able  to  diagnose  the  dis- 
location, apart  from  the  lordosis  and 
the  duck's  gait,  by  the  movability  of 
the  femur  on  the  pelvis,  the  elevated 
level  of  the  trochanter,  and  the  detec- 
tion of  the  head  of  the  bone,  above  or 
behind  the  acetabulum.  Both  types  of 
cases  sometimes  require  examination 
under  an  anaesthetic.  The  only  affec- 
tion with  which  confusion  is  conceiv- 
able is  a  rachitic  curvature  of  the  femur, 
especially  if  this  is  accompanied  by 
a  bilateral  coxa  vara.  Such  children 
often  present  a  pronounced  lordosis, 
i.e.,  they  protrude  their  abdomen  for- 
wards, in  order  to  regain  the  equi- 
librium, which  is  disturbed  by  the 
curvature  of  the  femur  (fig.  378).  The 
gait  is  often  awkward,  and  resembles  the  waddling  in  the  case  of 
congenital  dislocation  of  the  hip.  The  similarity  of  the  conditions  is 
enhanced  by  the  fact  that  the  level  of  the  trochanters  is  raised  in 
coxa  vara  and  because  they  project  abnormally  far  at  the  sides  (see 
shape  of  hips  in  fig.  379). 

But  an  important  difference  is  afforded  by  the  abnormal  mobility 
in  congenital  dislocations,  m  contrast  to  the  restricted  movements  in 


Fig.  378.  —  Rachitic  coxa  vara,  with 
simultaneous  bending  of  the  shaft  of 
femur  and  tibia  outwards  and  for- 
wards, and  compensatory  lordosis. 


NON-TRAUMATIC    DEFORMITIES   AT   THE    HIP-JOINT 


637 


coxa  vara.  There  are,  however,  cases  of  coxa  vara  wherein  the  restric- 
tion of  movements  is  but  shght,  namely  the  coxa  vara  of  Httle  rachitic 
children,  and,  on  the  other  hand,  there  are  cases  of  congenital  disloca- 
tion— mostly  in  older  children — wherein  the  abnormal  mobility  has 
become  diminished.  If,  finally,  the  head  of  the  femur  is  only  slightly 
developed,  and  is  therefore  difficult  to  feel  as  a  separate  structure,  and 
if  the  dislocation  is  not  definitely  of  the  iliac  variety,  but  of  the  supra- 
cotyloid  varietv,  which,  exceptionally,  may  remain  in  that  position 
until  an  advanced  age,  it  is  quite  conceivable  that  the  case  may 
be  obscure  until  an  examination  is  made  under  an  anaesthetic. 
Trendelenburg  has  indicated  a  sign  which  may  be  valuable  in  such  a 
case.     He  points  out  that  when   a  normal   individual  stands  on  one 


Fig.  379. — Congenital  dislocation  of  right  hip  (seen  from  behind). 


foot,  the  opposite  half  of  the  pelvis  is  raised,  on  account  of  the 
muscular  fixation  of  the  joint.  In  an  individual  with  congenital 
dislocation,  this  fixation  of  the  joint  is  absent,  and  therefore  the 
opposite  half  of  the  pelvis  sinks.  However,  if  there  be  a  dislocation, 
anaesthesia  will  enable  the  head  to  be  felt,  and  the  oscillating  move- 
ment to  be  detected.  If  doubt  still  remains,  it  can  be  finally  cleared 
up  by  X-ray  examination. 

Infantile  paralysis,  once  affecting  the  gluteal  muscles,  may  involve 
the  beginner  into  difficulty.  The  lameness  is  very  similar  to  that  of 
dislocation  (paralvtic  limp).  The  trochanter  becomes  so  prominent, 
owing  to  the  atrophy  of  the  gluteal  muscles,  that  the  inexperienced  is 
apt  to  mistake  it  for  the  head  of  the  femur.  Owing  to  the  muscular 
paralysis  the  passive  movements  of  the  limb  are  very  extensive,  and  in 


638 


SURGICAL   DISEASES    OF   THE    EXTREMITIES 


old  cases  there  may  b 
paralysis  is  that  the 
he  became  ill  with 
spread  paralysis  wh 
examination  at  once 
pelvis,  and  that  the  pr 


Fig.  380. — Bilateral  rachitic  coxa 
vara.       Extreme   projection    of  the 


e  some  shortening.     But  the  history  in  infantile 
little  patient  previously  walked    quite  well,  that 
infective    symptoms,    and    had,    at   first,    wide- 
ich     gradually    subsided     somewhat.       Physical 
shows  that  the  femur  is  not  displaced  on  the 
■ominence  seen  under  the  glutei  is  not  the  head 
of  the  femur,  but  an   abnormally  evi- 
_         dent    trochanter.     Although    the    limb 
may   be    shortened,    the    level    of    the 
trochanter  is  not  raised,  showing  that 
the  whole  femur  is  shortened  and  not 
merely  displaced    upwards,  as    in   dis- 
location. 

Sometimes  genuine  dislocations  are 
associated  with  paralysis — not  congeni- 
tal, but  acquired  ^flr<7/v5/s.  In  infantile 
paralysis  they  are  unilateral,  and  depend 
upon  the  traction  of  the  unparalvsed, 
but    un  -  antagonized    adductors.      In 


trochanter  region. 


Fig.  381. — Rachitic  coxa  vara.    (Skiagram 

of  fig.  380.) 


congenital  spastic  paraplegia — Little's  disease — the  dislocations  may  be 
bilateral,  due  to  spastic  contraction  of  the  adductors.  The  paralysis 
may  predominate  the  clinical  picture  so  that  the  dislocation  may  be 
entirely  overlooked,  especially  in  bed-ridden  children,  although,  owing 
to  the  muscular  atrophy,  tlus  could  easily  be  detected  on  grasping 
the  hip. 


XOX-TRAU^IATIC    DEFORMITIES    AT   THE    HIP-JOIXT  639 

Progressive  muscular  atrophy  (fig,  377)  is  a  disease  which  at  first 
sight  may  suggest  congenital  dislocation  of  the  hip  because  of  the 
lordosis.  A  careful  examination  will,  however,  quickly  expose  the 
error. 

Congenitally  dislocated  hips  are  frequently  affected  in  the  course 
of  time  with  inflammatory  processes  of  the  nature  of  arthritis 
deformans,  causing  considerable  pain.  This  may  impel  the  patients 
to  seek  advice,  rather  more  than  for  the  deformity — a  circumstance 
which  may  be  of  diagnostic  significance. 

A  female  patient,  aged  24,  sought  advice  for  "  rheumatic  "  pains 
in  the  right  hip.  She  was  of  normal  girth,  but  short  in  stature,  and 
she  had  a  striking  stiff,  peculiar  measured  gait.  She  had  suffered 
with  her  hips  from  infancy,  and  had  always  been  treated  for 
'' general  weakness."  Examination  showed  a  congenital  bilateral 
dislocation  of  the  hip,  with  arthritic  changes  on  the  right  side.  The 
skiagram  showed  that  the  heads  of  the  femora  were  displaced  to  the 
extent  of  9  cm.,  and  that  a  new  joint  had  developed  on  either  side 
of  the  pelvis. 

The  slow  stiff  gait  was  very  remarkable  in  this  case.  Her  aesthetic 
taste  had  unconsciously  and  gradually  adapted  it  to  such  an  extent 
as  to  completely  conceal  the  waddling.  Some  female  patients  entirely 
lack  this  compensatory  influence,  and  the  term  "duck's  gait"  hardly 
does  justice  to  what  is  seen  in  some  advanced  cases. 

The  following  case  is  equally  significant.  A  female  patient, 
aged  36,  in  whom  some  "  weakness  "  of  the  left  leg  had  already  been 
detected  in  childhood,  began  to  suffer  pain  in  the  left  hip  and  to 
limp  when  she  w-as  31.  She  went  from  one  practitioner  to  the  other, 
and  was  considered  to  be  a  case  of  "  rheumatism."  This  diagnosis 
did  not,  however,  explain  the  shortening  of  li  cm.  Palpation  did 
not  reveal  anything  definite,  because  of  the  patient's  stoutness. 
A  skiagram  had  to  be  made  in  order  to  distinguish  between  the 
results  of  an  old  hip  disease,  or  of  an  injury,  and  congenital 
dislocation.  The  skiagram  was  in  favour  of  the  latter.  It  was  not 
the  dislocation  which  caused  the  patient  to  seek  advice  but  the 
secondary  arthritis. 

B.— COXA  VARA. 

If  the  head  of  the  temur  is  not  in  an  abnormal  position,  and  if  the 
bone  cannot  be  displaced  on  the  pelvis,  there  cannot  be  any  dis- 
location. But  if,  despite  these  circumstances,  the  level  of  the 
trochanter  is  raised,  it  must  be  caused  by  the  bending  of  the  neck 
of  the  femur. 

In  some  cases  coxa  vara  depends  upon  the  diminution  of  the 
obtuse  angle  at  the  neck  of  the  femur,  and,  finally,  its  decrease  to 
a  right  angle  (fig.  381),  or  even  to  an  acute  angle  {coxa  adducta  of 
Kocher).     In   other   cases  the  head  of  the   bone  is  bent  downwards 


640 


SURGICAL   DISEASES   OF   THE    EXTREMITIES 


and  backwards,  while  both  the  head  and  the  neck  undergo  a  spiral 
twist  backwards,  when  the  neck  is  in  a  normal  position.  {Coxa  vara 
in  the  strict  sense  of  the  word  according  to  Kocher). 

The  causes  of  this  bending  are  the  same  as  in  the  case  of  other 
bony  deformities — i.e.,  rickets  in  infancy,  the  strain  of  abnormal 
weight  during  the  period  of  growth,  and  in  rare  cases  osteomalacia 
in  later  years.  In  addition,  there  are  cases  of  false  coxa  vara,  due 
to  osteomyelitis,  tubercle  and  injury,  and,  finally,  very  rare  examples 

of  congenital  coxa  vara. 

If  the  cause  is  rickets  the 
disease  is  usually  bilateral,  but 
if  the  condition  has  been  caused 
by  abnormal  weight-bearing  (coxa 
vara  of  adolescents),  it  may  be 
either  unilateral  or  bilateral. 

But  even  in  this  case  we 
must  assume  some  abnormality 
in  the  constitution  of  the  bone. 
It  matters  very  little  whether  we 
classify  it  with  late  rickets  or  desig- 
nate it  in  some  other  way,  because 
we  are  not  fully  acquainted  with 
the  nature  of  late  rickets. 

Let  us  first  consider  in  detail 
a  case  of  rachitic  coxa  vara  in  a 
child.  The  posture  of  the  leg 
and  foot  is  as  normal  as  the 
rachitic  curvature  permits,  but  we 
are  struck  by  the  extreme  pro- 
jection and  the  great  elevation 
of  the  trochanters.  The  gait  of 
the  little  patient  is  exceedingly 
clumsy,  and  may  sometimes  be 
characterized  as  slightly  waddling. 
The  movement  of  the  projecting 
trochanter,  which  is  visible  under 
the  skin,  resembles  somewhat  the 
movement  of  the  head  of  the  femur  under  the  gluteal  muscles  in 
congenital  dislocation  of  the  hip.  But,  as  already  stated,  the  resem- 
blance is  merely  superficial,  for  in  coxa  vara  there  is  only  one  pro- 
tuberance, whereas  in  dislocation  there  are  tivo.  On  examining  the 
individual  movements  we  find  that  there  is  freedom  of  flexion,  that 
external  rotation  is  normal  or  only  slightly  restricted,  but  that  abduc- 
tion is  diminished  or  almost  impossible.    The  only  abnormality  shown 


Fig.  382.— Left  sided  coxa  vara  in  a  youth. 


NON-TRAUMATIC   DEFORMITIES   AT   THE    HIP-JOINT  641 

by  the  skiagram  (fig.  381)  is  adduction  of  the  neck  of  the  femur  towards 
the  shaft,  usually  to  an  angle  of  about  90° — coxa  addiicta. 

If  we  examine  the  rest  of  the  skeleton  we  are  almost  sure  to  find 
other  signs  of  rickets  in  the  bones  (fig.  378). 

The  restriction  of  abduction  varies.  In  young  children  it  is  slight, 
but  later  on,  between  the  eighth  and  tenth  year,  it  may  be  very  pro- 
nounced and  constitute  the  most  troublesome  symptom. 

In  unilateral  coxa  vara  the  distance  between  the  anterior  superior 
spine  and  the  malleolus  is  shortened  in  the  affected  limb,  and  there 
is  corresponding  luiilateral  lameness.  This  is,  however,  a  condition 
which  is  much  rarer  in  rickets  than  the  coxa  adducta  which  occurs 
after  fractures  of  the  neck  of  the  femur,  osteomyelitis,  or  tubercle. 


Fig.  383. — Severe  bilateral  coxa  vara,  patient,  aged  15.     Rachitic  form. 

A  more  complicated  clinical  picture  presents  itself  in  children,  in 
cases  of  coxa  vara  in  the  strict  sense  of  the  ivord,  i.e.,  bending  of  the 
head  downwards  and  backwards,  often  with  simultaneous  twisting  of 
the  neck. 

For  the  head  to  retain  its  normal  relation  to  the  acetabulum,  the 
shaft  of  the  bone,  and  therewith  the  whole  limb,  would  have  to 
assume  a  position  of  adduction,  external  rotation  and  hyperextension. 
In  order  to  improve  upon  this  impossible  position,  the  limb — head  and 
shaft — executes  a  movement  which  is  composed  of  abduction,  inward 
rotation  and  flexion.  The  more  pronounced  the  deformity,  the  more 
IS  the  whole  range  of  the  movement  in  these  directions  taken  up  in 
merely  attaining  a  normal  posture,  and  the  less  is  it  possible  to  abduct, 


642 


SURGICAL   DISEASES   OF   THE    EXTREMITIES 


invert  or  flex  the  limb  any  further.  These  simple  considerations  explain 
the  disturbances  of  function,  which  we  meet  in  this  form  of  coxa  vara. 
The  gait  of  a  patient  with  a  unilateral  affection  presents  the  same 
lameness  as  a  case  of  painless  stiffening  and  shortening  of  the  limb. 
The  pelvis  is  pushed  forwards  at  each  step  and  the  limb  proceeds  as  a 
rigid  whole  with  the  pelvis.  When  the  affection  is  bilateral,  there  is 
the  peculiar  gait  wherein  the  pelvis  oscillates  around  a  vertical  axis 
with  every  step.  We  will  also  notice  that  the  affected  limb  is  always 
held  in  a  position  of  eversion,  an  obvious  result  of  the  downward 
inclination  of  the  head,  which  is  no  longer  fully  compensated  for. 
The  skiagram  shows  mainly  a  downward  displacement  of  the  head, 
in  the  epiphyseal  line,  on  a  normally  placed  neck  (fig.  384). 


EiG.  384a. — Coxa  vara  in  a  youth.   Bending 
in  the  vicinity  of  the  epiphyseal  line. 


Fig.  384b. — Healthy  side  in  same 
patient. 


We  may  summarize  what  has  already  been  said,  in  regard  to  coxa 
addiida,  as  follows  :  Proininence  and  elevation  of  the  level  of  the 
trochanter,  restricted  abduction,  and  shortening  if  tlie  affection  is  uni- 
lateral. In  regard  to  coxa  vara  in  the  strict  sense  of  the  term,  we 
may  summarize  thus  :  Prominence  and  elevation,  of  tlie  level  of  the 
trochanter  with  external  rotation  and  restriction  of  abduction.  Internal 
rotation  and  flexion,  and  shortening  with  lameness  of  one  side  if  the 
affection  is  imilateral. 

These  points  should  facilitate  the  differential  diagnosis  from  other 
diseases  of  the  hip.  We  have  already  discussed  the  differential  diagnosis 
from  congenital  dislocation  of  tlie  hip. 


ACUTE    INFLAMMATORY    DISEASES    OF   THE    HIP-JOINT  643 

Sometimes  unilateral  coxa  vara  in  a  youth  is  mistaken  for  coui- 
■mencing  Iiip  disease.  Coxa  vara  has,  like  flat  foot,  a  painful  stage 
which  may  easily  be  regarded  as  some  inflammatory  affection. 

A  young  man  (fig.  382)  sought  advice  for  commencing  "hip 
disease."  He  limped  slightly  towards  the  left,  but  two  facts  were 
noticeable  at  first  sight:  the  limp  was  not  painful,  as  he  planted  his 
left  foot  down  quite  firmly  without  any  special  care.  It  rather 
appeared  to  be  due  to  shortening.  In  addition,  the  foot  was  con- 
siderably everted.  This,  of  course,  excluded  hip  disease.  The  stage 
wherein  eversion  exists  is  accompanied  by  some  abduction  and 
apparent  lengthening.  This  stage  is  also  so  painful  that  it  is  im- 
possible to  bring  the  foot  down  to  the  ground,  without  special  care. 
Our  thoughts,  therefore,  proceeded  in  another  direction.  We  measured 
the  leg  and  found  2  cm.  of  shortening,  which  is  hardly  possible 
in  early  hip  disease.  The  level  of  the  trochanter  was  definitely  raised. 
On  testing  the  movements  it  was  found  that  abduction,  flexion  and 
inward  rotation  were  restricted.  This  established  the  diagnosis  of 
coxa  vara,  and  the  skiagram  could  do  nothing  but  confirm  it. 

Complete  rest  with  the  .application  of  an  extension  apparatus 
relieve  the  painful  symptoms  much  more  quickly  than  in  the  case  of 
hip  disease,  which  affords  a  further  proof  of  the  accuracy  of  the 
diagnosis. 

If  a  young  man  presents  the  symptoms  of  a  unilateral  coxa  vara, 
we  must,  as  we  have  already  seen,  investigate  his  clinical  history  for 
an  injury,  before  attributing  them  to  a  deformity  produced  by 
mechanical  conditions.  If,  however,  such  an  injury  cannot  be 
recalled  by  the  patient,  we  must  not  endeavour  to  persuade  him  of 
its  occurrence. 


CHAPTER   XCIV. 


ACUTE    INFLAMMATORY   DISEASES   OF   THE 

HIP-JOINT. 

A  PATIENT  is  suddenly  seized  with  severe  pains  in  the  hip,  and  is 
unable  to  move  his  leg  with  freedom.  We  have  excluded  acute 
disease  of  neighbouring  structures,  such  as  phlegmonous  inflamma- 
tion of  the  crural  or  inguinal  glands,  or  an  acute  abscess  of  the  pelvic 
fossa.  It  therefore  only  remains  to  decide  whether  the  case  is  one  of 
acute  arthritis  of  the  hip-joint,  or  osteomyelitis  of  the  shaft  of  the 
femur,  or  even  of  the  pelvis. 

It  is  true  that  there  is  pain  with  every  movement  in  osteomyelitis, 
just  as  there  is  in    hip   disease,   but  nevertheless  passive  movements 


644  SURGICAL   DISEASES   OF   THE   EXTREMITIES 

may  be  carried  out  within  certain  limits,  if  due  care  is  exercised.  The 
local  pain  on  pressure  does  not  correspond  to  the  region  of  the  joint^ 
but  has  its  highest  point  at  some  distance  from  it  below  the  trochanter, 
at  the  extreme  limit  of  the  osteomyelitis — or,  on  the  other  hand,  up- 
wards towards  the  pelvis.  If  there  is  secondary  involvement  of  the 
joint  the  symptoms  of  the  two  diseases  coalesce,  but  we  ought  to  be 
able  to  decide  the  sequence  of  events  by  the  fact  that  the  pain  on 
pressure  extends  comparatively  far  either  upwards  or  downwards,  and 
by  the  thickening  of  the  bone.  In  acute  hip  disease,  however,  in- 
cluding a  circumscribed  osteomyelitis  of  the  head  and  neck  of  the 
femur,  we  are  struck  from  the  very  beginning  with  the  intense  pain- 
fulness  of  any  passive  movement  of  the  joint,  if  not  by  its  complete 
muscular  fixation,  no  matter  in  which  position  this  fixation  has  taken 
place.  The  maximum  pain  on  pressure  is  in  the  vicinity  of  the 
head  of  the  bone,  i.e.,  beneath  the  middle  of  Poupart's  ligament.  On 
inspection  and  palpation  it  may  be  noted  that  this  region  is  fuller 
than  on  the  healthy  side.  The  pyrexia  proves  that  some  acute 
inflammatory  disease  exists. 

What  is  the  nature  of  this  inflammation?  If  several  other  joints 
are  involved  simultaneously,  or  in  rapid  succession,  we  should  think 
of  acute  articular  rheumatism — but  one  must  be  sure  that  only  the 
joints  are  affected.  If  the  disease  is  limited  to  the  hip,  and  the 
patient  is  young,  the  condition  is  most  probably  one  of  acute  osteo- 
myelitis of  the  neck  and  head  of  the  femur,  involving  also  the  joint. 
This  diagnosis  becomes  quite  certain  if  other  areas  of  bone  disease 
exist,  or  if  some  suppurative  inflammation  is  actuallv  present  at  the 
time,  or  has  recently  subsided. 

If  the  patient  is  a  child  convalescent  from  scarlet  fever,  we  know 
that  the  case  is  one  of  scarlatinal  arthritis,  which  may  recover  without 
incision,  and  with  complete  restoration  of  function,  or  which  may 
rapidly  destroy  the  joint.  Similar  forms  of  inflammation  of  the  hip 
may  more  rarely  come  on,  after  typhoid  fever,  small-pox  or  measles. 
The  hip  is  sometimes  involved  in  puerperal  articular  disease.  In 
default  of  any  of  these  more  frequent  causes,  we  must  seek  other  possible 
portals  of  entry  for  organisms  of  inflammation,  and  we  should  not 
forget  gonorrhoea.  Subacute  inflammation  of  the  hip  may  occur  in 
secondary  syphilis  and  in  the  congenital  disease,  but  it  is  rare.  Some- 
times it  is  quite  impossible  to  determine  how  the  infection  entered, 
or  to  discover  any  cause. 

This  is  especially  true  of  certain  cases  of  acute  hip  disease  in  little 
children,  who  recover  after  simple  evacuation  of  the  pus,  sometimes 
without  leaving  any  serious  derangement.  Bacteriological  examina- 
tion should  never  be  neglected  in  this  type  of  case,  lest  one  overlooks 
an  acute  onset  of  tubercle. 


ACUTE    INFLAMMATORY   DISEASES   OF   THE    HIP-JOINT  645 

The  organisms  of  acute  suppuration  sometimes  give  rise  to  a  form 
of  inflammation  which  is  mistaken  for  tubercle,  because  staphylococcic 
and  streptococcic  infections  of  the  neck  of  the  femur  do  not  always 
produce  their  familiar  clinical  picture.  On  the  contrary,  the  disease 
may  run  such  a  mild  course,  despite  its  acute  onset,  that  it  easily 
suggests  tubercle,  unless  a  very  reliable  history  is  at  hand.  The 
records  of  von  Brun's  clinic  have  shown  that  this  mistake  is  by  no 
means  rare. 

The  following  is  a  typical  case  : — 

We  were  consulted  about  a  lad  aged  12,  who  presented  all  the 
symptoms  of  early  hip  disease — moderate  pain  on  axial  pressure,  and 
on  pressure  over  the  trochanter,  fixation, of  joint  in  a  position  of  slight 
flexion,  adduction  and  inversion  ;  temperatvn-e  practically  normal.  This 
condition  had  existed  unchanged  for  several  weeks.  Had  we  had  no 
reliable  history,  we  might  have  assumed  that  the  case  was  tubercular. 
But  as  a  matter  of  fact,  the  patient  had  been  admitted  to  hospital  with 
the  diagnosis  of  acute  osteomyelitis  of  the  upper  end  of  the  femur.  The 
disease  had  started  suddenly,  with  severe,  though  transitory,  fever.  We 
accepted  the  diagnosis  of  the  family  practitioner,  and  it  was  confirmed 
during  the  course  of  the  next  month  by  the  development  of  osteo- 
myelitis of  the  shaft  of  left  humerus,  with  sequestrum  formation.  The 
lad  had  complained  of  pain  in  the  left  arm  from  the  beginning,  but 
he  laid  no  stress  on  it,  as  his  hip  symptoms  were  much  more 
distressing. 

One  word  in  reference  to  the  results  of  these  inflammations. 
As  long  as  the  measurement  between  the  anterior  superior  spine  and 
malleolus  is  of  normal  length,  having  regard  to  the  position  of  the  leg, 
and  the  tip  of  the  trochanter  is  at  the  correct  level,  the  case  is  one  of 
pure  arthritis.  But  if  there  is  sudden  shortening,  or  if  the  trochanter 
becomes  displaced  upwards,  there  must  be  some  pathological  disloca- 
tion, usually  backwards,  or  a  separation  of  the  epiphysis.  The  former 
is  more  frequent  after  typhoid  or  scarlet  fever  ;  the  latter,  after  osteo- 
myelitis, in  which  condition  a  fracture  near  the  shaft  may  occur. 
The  actual  state  of  affairs  can  be  determined  by  careful  examination. 
If  the  limb  is  slightly  everted  and  can  be  moved  hither  and  thither  on 
the  pelvis,  and  if  soft  crepitus  can  be  felt,  a  separation  of  tlie  epiphysis 
is  present.  If  the  leg  is  in  the  position  of  a  posterior  dislocation,  i.e.^ 
flexion,  adduction  and  inversion,  and  if  the  head  of  the  femur  is  felt 
under  the  gluteal  muscles  it  is  obvious  that  a  dislocation  is  present. 

There  is  another,  a  further,  possibility,  which  is,  however,  rare  in 
acute  arthritis,  but  may  lead  to  an  error  of  diagnosis. 

A  little  girl  was  suffering  from  scarlatinal  hip  disease  and  her  limb 
was  shortened  and  in  a  position  of  eversion.  It  was  possible  to  move 
the  femur  on  the  pelvis,  and  soft  crepitus  was  felt.  We  diagnosed 
inflammatory  separation  of  the  epiphysis.  The  skiagram,  however, 
showed  severe  destruction  of  the  upper  border  of  the  acetabulum  and 
partial  destruction  of  the  head  of  the  femur,  which  was  not  detached. 


646  SURGICAL   DISEASES   OF   THE    EXTREMITIES 

The  case  was  really  one  of  pathological  dislocation  in  which  there  was 
no  pathognomonic  malposition,  and  in  which  there  was  no  possibihty 
of  successful  reduction,  in  consequence  of  the  destruction  of  the  joint. 
As  soon  as  the  residue  ot  the  head  was  brought  into  a  normal  position, 
it  glided  backwards  again,  because  of  the  destruction  of  the  upper 
border  of  the  acetabulum.  An  operation  was  performed  subsequently 
-and  this  confirmed  the  X-rav  diagnosis. 


CHAPTER    XCV. 

CHRONIC  INFLAMMATORY  DISEASES  OF  THE  HIP. 

Chroxic  mflammatory  diseases  of  the  hip  are  mainly  comprised 
within  two  groups.  The  one  includes  tubercular  coxitis,  the  other 
embraces  all  that  is  understood  by  the  term  chronic  rheumatic 
arthritis.  There  are  other  rare  conditions,  which  will  be  referred  to 
when  discussing  differential  diagnosis.  An  approximate  distinction  is 
furnished  by  the  circumstance  that  the  tubercular  disease  affects 
growing  individuals,  while  the  non-tubercular  arthritis  affects  adults  ; 
but  the  borderland  cases  which  lie  between  the  two,  cause  difficulty 
in  diagnosis. 

A.— TUBERCULAR   HIP    DISEASE. 

The  diagnosis  of  tubercle  is  forced  upon  us  if  a  child  begins  to 
complain  of  feeling  tired  and  has  a  painful  limp  after  walking  for  some 
distance,  if  the  gluteal  fold  is  obliterated  and  some  muscular  atrophy 
on  the  affected  side  is  also  possibly  noticeable.  As  the  limp  is  not 
permanent  at  first,  but  only  comes  on  when  the  patient  is  tired,  and  as 
it  can  be  suppressed  when  an  effort  is  made  to  do  so,  it  has  been  called 
a  "  voluntary  limp" — an  expression  which  constitutes  an  unjustifiable 
reproach.  The  progress  of  the  case  is  a  comment  on  its  "voluntary" 
nature.  Sometimes  the  child  complains  more  about  the  knee  than 
about  the  hip,  but  a  cursory  examination  will  show  that  the  knee-joint 
is  free. 

Having  examined  the  gait  of  the  child  with  his  clothes  off,  we  lay 
him  upon  a  flat  table  and  direct  him  to  extend  both  legs  completely. 
A  hollow  is  observed  to  form  in  the  back,  so  that  the  hand  can  be 
passed  flat  under  the  lumbar  region.  If  we  make  the  back  fit  closely 
against  the  table,  the  knee  of  the  affected  side  becomes  slightly  raised. 
This  preliminarv  examination  suffices  to  show  that  the  hip  is  held  in  a 


CHRONIC    INFLAMMATORY    DISEASES    OF   THE    HIP 


647 


constrained  position  of  slight  flexion,  although  otherwise  the  limb  may 
either  be  abducted  and  everted,  or  adducted  and  inverted,  both  positions 
being  met  with  in  the  early  stages. 

If  we  cannot  get  the  back  to  lie  close  against  the  table,  we  may 
adopt  the  simple  and  painless  method  of  Thomas,  i.e.,  we  flex  the 
healthy  hip  as  much  as  possible  in  order  to  throw  the  pelvis  backwards,, 
and  thus  the  spinal  column  will  certainly  be  forced  close  against  the 
table.  If  there  is  the  slightest  degree  of  flexion  on  the  diseased  side,, 
the  knee  will  then  be  raised,  so  that,  at  any  rate,  the  hand  can  be 
passed  under  it  (figs.  385  and  386). 


Fig.  385. — Lefl-sided  hip  disease.     The  position  of  slight  flexion  compensated  for  by 

the  lumbar  lordosis. 


Fig.  386. — Same  case.     The  flexion  demonstrated  by  Thomas's  rnanceuvre. 


We  then  proceed  to  a  careful  examination  of  the  separate  move- 
ments, as  compared  with  the  healthy  side.  The  more  limited  flexion,, 
extension,  adduction,  abduction,  external  and  internal  rotation  are,  the 
more  does  the  patient  endeavour  to  transfer  these  movements  to  the 
lumbar  spine,  and  he  moves  his  pelvis  and  leg  as  one  fixed  whole.  In 
other  words,  the  pelvis  participates  in  the  movements.  We  must  then 
inquire  whether  this  fixation  depends  upon  pure  muscular  spasm,  or 
upon  any  organic  changes  in  the  joint.  If  the  degree  of  fixation  after 
a  long  rest  dift'ers  from  the  degree  present  when  the  patient  is  very 
tired,  it  would  indicate  a  muscular  origin,  but  if  there  is  no  difference, 
the  rigidity  must  depend  upon  causes  within  the  joint.     An  absolute 


648 


SURGICAL    DISEASES    OF   THE    EXTREMITIES 


decision  can  only  be  arrived  at  by  examination  under  an  anaesthetic, 
when  muscular  fixation  vanishes  forthwith  without  any  forcible 
manipulation.  Abduction  and  rotation  are  the  movements  which  are 
generally  first  interfered  with.  If  the  adductors  become  tense  on 
attempting  to  perform  abduction  rapidly,  the  hip-joint  is  certainly 
involved,  even  if  extension  and  flexion  remain  perfectlv  free. 


Fig.  387. — Early  stage  of  hip 
disease  on  right  side,  with  external 
rotation ^  Jlexton  and  abduction. 


Fig.  388.  —  Early  stage  of  hip 
disease  on  right  side,  ivith  flexioi, 
adduction  and  inward  rotation. 


It  may  happen  in  this  stage  that  all  s^-mptoms  disappear  after 
a  few  weeks'  rest  in  bed,  so  that  one  thinks  an  error  in  diagnosis 
has  been  made.  But  the  symptoms  return  in  a  few  months,  or  even 
after  a  few  years,  and  the  classical  picture  of  hip  disease  develops. 

If  we  are  not  quite  clear  about  the  limitation  of  abduction  we 
direct  the  patient,  after  taking  off  his  clothes,  to  spread  out  his  legs  as 
inuch  as  possible  while  standing.     Any  asymmetry  which  then  exists 


CHRONIC    INFLAMMATORY   DISEASES   OF   THE    HIP 


649 


in  the  posture  of  the  leg  or  back  is  an  indication  that  abduction   is 
interfered  with. 

A  certain  amount  of  importance  attaches  to  the  division  of  hip 
■disease  into  stages,  in  accordance  with  the  posture  of  the  hmb.  As 
Konig  has  shown,  the  patient  endeavours  to  spare  his  hip-joint  as 
much  as  possible  in  all  stages  of  the  disease.  For  this  purpose  the 
position  of  slight  abduction  and  external  rotation,  with  a  little  flexion, 
is  the  most  useful,  as  long  as  the  patient  walks  without  crutches 
(fig.  387).     But  if  the  patient  does  go  about  on  crutches,  he  raises  his 


Fig.  389. — Advanced  hip  disease  of  left  side  with  extreme  flexion  and  abduction. 


Fig.  390. — Advanced  hip  disease  of  left  side,  with  internal  rotation,  adduction  and  flexion. 


diseased  leg,  that  is  to  say,  he  flexes  it  more,  but  still  holds  it  in 
abduction.  If  the  patient  takes  to  his  bed  in  the  earlier  stage  of  his 
disease,  he  supports  his  flexed,  diseased  leg  on  the  healthy  one,  thus 
bringing  it  into  the  position  of  adduction  and  internal  rotation 
(figs.  389  and  390). 

>-^  There  is  an  anatoiuical  cause  for  this  position,  if  the  head  of  the 
bone  has  left  its  normal  situation  and  has  become  displaced  posteriorly, 
or  backwards  and  upwards,  either  through  destruction  of  the  capsule 
or  gradual  destruction  of  the  posterior  border  of  the  acetabulum 
(so-called     displacement     of     the     acetabulum     [Pfannenwanderung] 


650 


SURGICAL   DISEASES    OF   THE    EXTREMITIES 


fig-  391)-  The  position  then  assumed  is  one  of  subluxation  or  even 
of  dislocation. 

After  testing  the  power  of  movement  we  proceed  to  palpation^ 
which,  combined  with  inspection,  will  show  v;hether  any  abnormal 
swelling  exists.  The  principal  swellings  to  be  thought  of  are  enlarge- 
ment of  the  inguinal  glands  and  abscesses  which  have  made  their  way 
to  the  surface.  These  usually  appear  in  front  (see  fig.  385,  where  there 
is  an  abscess  below  the  anterior  superior  spine),  but  also  occur  on  the 
outer  and  on  the  posterior  surface  of  the  hip. 

We  next  examine  for  pain. 


Fig.   391. — Hip    disease  with    "displacement  of  acetabulum"  and  coxalgic  peh 
(Skiagram  of  fig.  385.)     Small  sequestrum  at  x. 


We  test  for  pain  on  direct  pressure,  where  the  joint  is  most 
accessible,  ?'.^.,  in  the  front,  just  below  the  middle  of  Poupart's 
ligament.  This  pain  is  often  an  early  sign  of  hip  disease,  although  it 
is  not  so  significant  as  loss  of  power  of  movement.  Importance 
also  attaches  to  indirect  pain,  elicited  by  force  applied  in  the  long 
axis  of  the  femur  or  to  the  trochanter.  We  have  already  seen  that 
any  movement,  carried  out  to  an  extreme  degree,  is  painful. 

The  differential  diagnosis  raises  the  following  considerations  : — 
{a)   If  it  is  quite  evident  that  there  is  actual  disease  of  the  hip-joint 


CHRONIC   INFLAMMATORY   DISEASES    OF   THE    HIP  651 

itself,  we  must  first  exclude  the  subacute  foruis  of  iufectivc  hip  disease. 
For  this  purpose  it  is  necessary  to  give  due  weight  to  all  the  points 
advanced  in  the  previous  chapter,  and  only  diagnose  tubercle  in  the 
absence  of  any  other  cause. 

As  already  remarked  in  the  previous  chapter,  an  acute  onset  of  hip 
symptoms  indicates  an  acute  infective  origin,  even  if  the  disease 
develops  into  a  chronic  condition.  The  sudden  rupture  of  a  tuber- 
culous periarticular  focus  into  a  joint  also  causes  acute  symptoms, 
including  fever,  but  as  a  rule  this  event  would  have  been  preceded  by 
slight  articular  symptoms,  pointing  to  tubercle.  A  rigor,  or  herpes 
labialis,  accompanying  the  acute  exacerbation,  are  indications  agaiust 
tubercle. 

If  the  onset  is  very  gradual,  the  possibility  of  tubercle  must  be 
entertained  even  if  the  hip  symptoms  have  followed  some  acute  infec- 
tious disease.  A  child  who  begins  to  limp  in  the  slightest  degree  a 
few  weeks  after  measles  is  probably  the  subject  of  early  hip  disease, 
the  measles  having  prepared  the  soil  for  the  tubercle. 

We  must  next  exclude  the  so-called  chronic  rheum  at  ic  arthritis, 
which  we  shall  deal  with  at  the  end  of  the  chapter. 

We  have  already  seen  that  congenital  dislocations  of  the  hip  and 
that  coxa  vara  are  subject  to  irritative  stages,  wherein  some  confusion 
with  hip  disease  is  quite  conceivable.  But  such  an  error  can  be 
avoided  by  careful  examination.  The  same  applies  to  the  hip 
symptoms  which  eventually  arise  in  fracture  of  the  neck  of  the  femur, 
and  which  belong  to  coxa  vara  traumatica. 

We  should  think  of  primary  or  secondary  malignant  growth, 
including  hydatid  cyst,  if  the  features  of  the  case  do  not  completely 
accord  with  hip  disease,  especially  if  the  slight  limitation  of  move- 
ment and  its  relative  painlessness  present  a  striking  contrast  to  the 
severe  and  spontaneous  radiating  pains. 

(6)  Diseases,  independent  of  the  joint,  may  simulate  hip  disease,  by 
causing  flexion  of  the  hip  and  pain  in  its  vicinity,  leading  to  a  painful 
limp. 

The  most  frequent  cause  of  spastic  flexion  of  the  hip,  not  due  to 
joint  disease,  is  a  burrowing  abscess  from  a  tubercular  spine,  or  pelvic 
tubercle.  This  condition  may  resemble  hip  disease  so  closely  that 
examination  of  the  spinal  column  and  palpation  of  the  pelvic  fossa  are 
always  essential  in  cases  of  spastic  flexion  of  the  hip. 

The  diagnosis  is  easy  if  a  dorsal  curvature  is  evident,  or  if  an 
abscess  is  found  filling  up  the  iliac  fossa.  But  matters  are  not  always 
so  simple.  The  curvature  may  be  quite  absent  in  adults,  and  the 
connection  of  the  abscess  with  the  spinal  column  may  be  limited  to  a 
narrow  sinuous  track.  In  abscess  due  to  spinal  disease,  however, 
abduction  and  rotation  are  usually  free  at  the  hip,  whereas  these 
movements  suffer  first  if  the  joint  itself  is  affected.  A  conclusion  may 
also  be  based  on  a  skiagram. 

42 


652  SURGICAL   DISEASES   OF   THE   EXTREMITIES 

In  rare  cases,  a  paranephritic  or  appendicular  abscess  may  cause 
spastic  flexion  of  the  hip,  and  an  inadequate  examination  may  lead  to 
a  wrong  diagnosis. 

Effusion  into  the  iliacns  bnrsa  may  also  lead  to  a  wrong  diagnosis 
because  of  the  spastic  flexion  and  the  swelling  immediately  over  the 
hip-joint.  But  as  abduction,  adduction  and  rotation  are  quite  free, 
despite  the  spastic  flexion,  such  an  error  ought  not  to  be  made. 

Unless  attention  is  paid  to  the  free  mobility  of  the  joint,  sciatica 
and  periarticular  neuralgia  are  liable  to  be  mistaken  for  early  hip 
disease,  more  especially  in  connection  with  gynaecological  conditions. 
In  some  cases  of  hysteria  there  appears  to  be  a  real  contracture  at  the 
joint ;  but  symptoms  usually  vanish  on  correct  treatment  by 
suggestion. 

It  is  sometimes  difficult,  in  the  case  of  a  young  girl,  to  decide  at 
the  first  examination  whether  the  condition  is  hysterical  or  the  early 
stage  of  hip  disease.  The  family  history  as  well  as  the  previous  history 
must  be  taken  into  consideration.  I  have  seen  a  girl  simulate  several 
tubercular  joints  in  the  course  of  a  year,  but  the  contractures  rapidly 
disappeared  after  appropriate  psychical  treatment.  In  another  case, 
I  was  at  first  inclined  to  diagnose  hysteria,  because  the  symptoms 
disappeared  at  times  ;  but  the  sequel  showed  that  hip  disease  really 
existed. 

The  foregoing  considerations  having  led  us  to  the  diagnosis  of 
tubercular  hip  disease,  we  must  next  endeavour  to  determine  the  variety 
and  degree  of  the  disease. 

It  would  be  interesting  to  know  whether  the  case  is  one  of  pure 
synovitis,  or  whether  there  has  been  a  primary  focus  in  the  pelvic  bone 
or  femur.  A  diagnosis  of  pure  synovitis  can  only  be  made,  as  in 
other  joints,  by  the  exclusion  of  primary  bone  disease.  But  as  this 
usually  causes  no  special  clinical  signs,  and  cannot  as  a  rule  be  directly 
demonstrated,  owing  to  the  inaccessibility  of  the  joint,  we  must  remain 
uncertain  of  this  point  unless  a  skiagram  is  taken.  If,  however,  acute 
exacerbations  occur,  and  subside  rapidly  on  complete  rest,  we  may 
suspect  the  presence  of  diseased  bone  close  to  the  joint,  which  has 
not  yet  extended  into  it,  but  is  nevertheless  capable  of  producing  slight 
attacks  of  serous  coxitis. 

If  a  tubercular  abscess  appears  in  the  neighbourhood  of  the  joint, 
which,  however,  remains  free,  we  should  think  of  the  possibility  of  a 
para-articular  focus  of  disease  which  has  penetrated  externally.  Such 
a  case  is  not  really  one  of  coxitis,  as  the  joint  is  free. 

If  severe  pain  is  felt  when  force  is  applied  to  the  joint,  one  may  be 
tempted  to  diagnose  primary  disease  of  the  bone  ;  but  such  a  con- 
clusion is  not  reliable  because  the  same  pain  would  be  elicited  if  the 
bone  disease  were  secondary.  Pain  caused  by  putting  weight  on  the 
joint  only  indicates  that  the  bone  is  involved  in  the  general  condition, 
but  one  cannot  even  be  quite  certain  of  this. 


CHRONIC   INFLAMMATORY   DISEASES   OF   THE    HIP 


653 


An  X-ray  exainination  is  the  best  method  for  the  early  diagnosis  of 
a  diseased  area  in  bone. 

If  the  bony  outhne  is  normal,  and  the  gap  representing  the 
cartilage  is  of  the  ordinary  size,  but  the  bone  itself  is  abnormally 
transparent  to  the  rays  (osteoporosis),  and  the  shaft  of  the  femur  is 
narrowed,  we  may  conclude  that  there  is  atrophy  from  disuse,  as  is 
usual  with  tuberculosis.  It  is,  however,  impossible  to  decide  whether 
a  primary  synovitis  exists,  or  whether  a  small  focus  of  disease  is 
present  in  the  bone. 

If  the  transparent  streaks  corresponding  to  the  articular  cartilage 
are  narrower  than  on  the  healthy  side,  but  the  picture  is  otherwise 
as  just  described,  we  must  assume  that  the  cartilage  has  already 
become  partially  absorbed. 

If  the  sharp    edge   of  the      ^^Hi^^^^^^^^^^^HnB^BK'  1 

head  of  the  bone  or  of  the 
acetabulum  is  replaced  by 
a  rough  irregular  border,  it 
means  that  the  cartilage  has 
been  destroyed  and  the  ad- 
jacent bone  eaten  away  ;  but 
even  this  condition  does  not 
exclude  a  primary  synovitis. 
But  whatever  the  aspect  of 
the  outline  of  the  bone  may 
be,  there  can  be  no  doubt 
about  the  existence  of  a  pri- 
mary focus  of  bone  disease  if 
there  is  a  transparent  area,  in 
the  head  (fig.  392),  the  neck, 
or  in  the  pelvis.  This  area 
may  either  be  sharply  defined 
or  confused  in  outline,  and 
is  sometimes  surrounded  by 
a  thick  zone  (osteosclerosis) 
with  a  more  opaque  structure 
in    the    centre    (sequestrum). 

In  the  later  stages  it  is  necessary  to  diagnose  the  secondary  changes, 
viz.,  displacement  of  the  acetabulum,  spontaneous  dislocation,  and 
separation  of  the  epiphysis.  The  differentiation  of  these  various 
processes  possesses  a  certain  therapeutic  importance. 

If  the  displacement  has  occurred  suddenly,  or,  at  any  rate,  has 
been  aggravated  suddenly,  for  example,  as  the  result  of  a  slight  injury, 
it  indicates  either  a  spontaneous  dislocation  or  a  separation  of  the 
epiphysis — or  even  fracture  of  the  neck  in  the  vicinity  of  a  large  area 
of  disease.  The  diagnosis,  as  between  fracture  and  dislocation,  is 
made  on  the  ordinary  principles.  It  should,  however,  be  noted  that 
when  the  joint  capsule  is  severely  affected,  the  displacement  is  less 
and  the  mobility  is   greater  than  in  a  traumatic  dislocation.     If  the 


Fig.  392. — Tubercular  focus  and  sequestrum  (x) 
in  head  of  femur. 


654  SURGICAL   DISEASES    OF   THE    EXTREMITIES 

displacement  occurs  gradually,  it  means  that  the  capsule  has  worn  away 
by  degrees,  and  the  head  of  the  bone  has  escaped  unnoticed,  or  that  the 
acetabulum  has  been  gradually  changing  its  position,  its  upper  border 
being  displaced  upwards,  or  upwards  and  backwards  by  pressure 
atrophy  (fig.  391).  The  acetabulum  thus  loses  its  circular  shape,  and 
assumes  that  of  a  fish  dish.  In  either  case  the  limb  takes  up  the 
position  of  adduction,  flexion,  and  internal  rotation.  It  is  quite 
impossible  clinically  to  distinguish  between  a  severe  degree  of  dis- 
placement of  the  acetabulum  and  a  dislocation  of  gradual  onset. 
This  is,  however,  of  no  importance,  because  such  dislocations,  unlike 
those  which  occur  suddenly,  are  incapable  of  reduction. 

The  distinction  may,  however,  be  made  by  means  of  a  skiagram, 
which  will  show  at  the  same  time  the  changes  which  the  entire  pelvis 
has  undergone  (coxalgic  pelvis,  fig.  391).  The  diseased  side  of  the 
pelvis  is  inclined  considerably  forwards  in  relation  to  the  other  side, 
having  rotated  on  a  frontal  axis  (Hofmeister). 

One  point  in  conclusion  :  A  tubercular  abscess,  which  is  not 
secondarily  infected,  should  never  be  opened  in  hip  disease.  If  the 
pus  is  required  for  examination,  it  must  be  obtained  by  an  aseptic 
exploratory  puncture,  and  if  it  is  desired  to  empty  the  abscess  this 
must  also  be  done  by  puncture  and  aspiration. 

B.— NON-TUBERCULAR    CHRONIC    HIP    DISEASE. 

If  a  patient  of  advanced  years  comes  complaining  of  his  hip,  our 
thoughts  will  run  in  a  totally  different  direction.  We  must  first  make 
sure  that  the  hip  is  really  affected,  and  that  the  case  is  not  one  of 
sciatica.  If,  on  testing  the  movements  of  the  limb  with  the  patient 
in  a  recumbent  position,  we  find  that  their  extent  is  restricted  and 
painful  at  their  extreme  limits,  we  should  think  of  one  of  the  various 
forms  of  non-tubercular  chronic  arthritis. 

Of  course  these  con-ditions  may  occur  in  young  people,  but  they 
are  as  rare  as  tubercular  hip  disease  is  among  adults. 

We  then  determine  the  degree  of  limitation  of  movement,  just  as 
in  a  tubercular  hip,  and  endeavour  to  find  the  cause.  If  some  move- 
ment still  exists,  we  must  note  whether  it  is  accompanied  by  grating. 

A  skiagram  will  show  the  presence  and  degree  of  osseous  changes, 
and  indicate  whether  the  arthritis  is  merely  the  result  of  some  other 
skeletal  deformity,  such  as  congenital  dislocation,  or  coxa  vara,  &c. 

We  then  examine  to  see  whether  the  hip  is  the  only  joint  affected, ' 
and  we  must  take  a  careful  clinical  history  with  special  reference  to 
the  various   forms    of    "  chronic  articular  rheumatism "  mentioned  in 
Chapter  LXXXII.     We  will  onlv  now,  however,  refer  to  the  conditions 
which  especially  affect  the  hip-joint. 

Anatomically,  the  most  important  are  those  processes  which  pro- 


CHRONIC   INFLAMMATORY    DISEASES   OF   THE    HIP 


655 


cluce  dcfonnitv,  partially  destructive  and  partially  proliferating  in 
character.  The  next  in  h-equency  are  the  forms  which  produce 
ankylosis. 

As  far  as  etiology  is  concerned,  the  cases  wherein  the  disease 
remains  permanently,  or  at  any  rate  for  a  long  time  localized  to  one 
joint,  are  of  more  interest  to  us  than  those  cases  wherein  the  multi- 
plicity of  the  affected  joints  facilitate  the  diagnosis.  In  the  former 
cases  the  disease  often  originates  in  an  injury,  sometimes  a  simple 
contusion.  The  younger  the  patient,  the  more  likely  this  causation. 
On  the  other  hand,  elderly  indi- 
viduals may  suffer  from  arthritis  of 
the  hip  with  deformity,  in  the 
absence  of  any  demonstrable  in- 
jury, i.e.,  senile  disease  of  the  hip. 
In  these  cases,  however,  the  disease 
does  not  always  remain  limited  to 
one  joint. 

In  the  absence  of  a  history  of 
injury,  an  examination  should  be 
made  for  nervous  diseases,  especi- 
ally tabes  and  syringo-myelia. 

Although  we  have  regarded 
adult  age  as  a  contra-indication  of 
tubercle,  it  may  still  be  necessary 
to  fall  back  upon  this  diagnosis  in 
cases  which  are  otherwise  insuffi- 
ciently explicable,  especially  if  the 
patient  has  a  tubercular  heredity, 
or  has  already  suffered  from  some 
tubercular  condition,  and  if  the 
pain  is  very  severe,  and  the  disease  progresses  somewhat  rapidly 
without  any  temporary  improvement.  Tubercular  hip  disease  has 
exceptionally  been  met  with,  even  at  the  age  of  80. 

The  diagnosis  is  sometimes  rendered  difficult  by  the  fact  that 
tubercle  may  occasionally  affect  several  joints,  and  thus  completely 
resemble  a  non-tubercular  chronic  arthritis.  Unless  some  typical 
sign  (osseous  focus,  sequestrum,  abscess)  occurs  in  one  joint,  the  case 
may  remain  obscure  for  years,  and  even  for  a  lifetime. 


Fig.  393--  Chronic  hip  disease  with 
deformity. 


656 


SURGICAL   DISEASES   OF   THE   EXTREMITIES 


CHAPTER   XCVI. 

SWELLINGS   AND  TUMOURS    OF    THE   THIGH. 

If  we  see  a  patient  who  has  suffered  a  severe  injury,  lying  with 
his  thigh  abducted  and  the  knee  shghtly  flexed,  and  the  whole  limb 
in  a  position  of  complete  eversion,  there  is  only  one  diagnosis 
possible,  fracture  of  the  shaft  of  the  femur;  if,  on  closer  observation, 
we  see  that  the  thigh  is  thickened  and  its  axis  slightly  bent  (fig.  394), 
all  doubt  is  dispelled. 


Fig.  394. — Fracture  of  the  shaft  of  the  right  femur. 


Fig.  395. — Acute  osteomyelitis  of  the  right  femur. 

If  a  little  child,  who  can  give  us  no  history,  and  whose  mother 
does  not  know  whether  it  has  had  a  fall,  presents  a  swelling  of  the 
thigh  and  cries  when  touched,  avoiding  any  movement  with  the  leg, 
the  question  of  fracture  or  of  the  early  stage  of  acute  osteomyelitis 
will  at  once  pass  through  our  mind  (fig.  396).  But  we  should  be 
relieved  from  doubt  by  finding  either  false  mobility  on  the  one  hand, 
or  general  and  local  rise  in  temperature  on  the  other  hand. 

If  the  swelling  is  only  slight,  but  bilateral,  the  case  is  neither 
fracture  nor  osteomyelitis,  but  is  probably  one  of  Barlow's  disease, 
in  which  very   painful    subperiosteal  effusions  of  blood  occur    over 


SWELLINGS   AND   TUMOURS   OF  THE   THIGH 


657 


the  femur.     This  diagnosis  is  verified  by  dark  bhiish  swelKng  of  the 
gums  where  the  teeth  have  erupted. 

If  a  young  person  becomes  ill  with  high  fever  and  severe  pain 
in  the  thigh,  and  diffuse  swelling  thereof  occurs  within  a  few  days, 
the  diagnosis  of  acute  osteomyelitis  is  clear. 

We  shall  refer  to  its  various  stages  in  connection  with  osteo- 
myelitis of  the  tibia.  A  com- 
parison of  fig.  394  with  fig.  395 
shows  how  closely  the  position 
of  the  femur  in  osteomyelitis 
resembles  the  position  in  frac- 
ture. 

Swellings  which  come  on 
gradually  and  without  fever  are 
not  necessarily  cold  abscesses 
or  new  growths,  but  may  be 
chronic  forms  of  staphylo-  or 
streptomycosis  of  the  bone.  In 
order  to  distinguish  between  the 
various  possibilities,  we  must 
decide  whether  the  swelling 
arises  from  the  soft  tissues  or 
from  the  bone.  This  can  only 
be  determined  by  its  degree  of 
mobility  in  relation  to  the  bone 
when  the  muscles  are  completely 
relaxed.  As  the  swellings  are 
not,  as  a  rule,  painful,  this  ex- 
amination can  usually  be  made 
without  an  anaesthetic.  If  a 
sarcoma,  originating  in  the  soft 
tissues,  has  once  become  ad- 
herent to  bone,  differentiation 
is  no  longer  possible.  The  his- 
tory may,   however,  indicate  that  Fjg.  396.— Acute  osteo-myelitis  of  the  right 

the  swelling  was  movable  at  first.  thigh. 


^.—SWELLINGS   OF   THE    SOFT   TISSUES. 

(i)  The  skin  and  snbcntancons  iissne  may  be  the  seat  of  soft 
fibroma — fibroma  moUuscum— lipoma,  especially  in  the  upper  part, 
lymphangioma,  and  occasionally  sarcoma,  originating  in  a  nasvus. 
Their  difierential  diagnosis  is  too  easy  to  require  any  consideration 
here. 

(2)  Swellings  of  the  deeper  soft  tissnes  may  arise  in  the  lymphatic 
glands,  blood-vessels,  muscles,  aponeurosis,  nerves,  and  the  loose 
connective  tissue. 

(a)  Swellings  of  the  Lyniphalie  Glands.— Tht  crural  glands,  which 


658  SURGICAL   DISEASES    OF   THE   EXTREMITIES 

alone  concern  us  here,  receive  lymph  from  the  whole  of  the  lower 
limb,  including  the  contiguous  region  of  the  perinaeum.  Anv  swelling 
in  this  region  demands  a  search  for  some  portal  of  entry  of  infection 
before  we  think  of  anything  unusual. 

A  young  man  came  to  the  out-patient  department  with  a  small 
swelling  in  the  crural  region.  The  swelling  pulsated,  or  at  any  rate 
appeared  to  do  so.  The  recently  qualified  assistant,  therefore, 
diagnosed  an  aneurism.  It  was,  however,  an  inflamed  gland  over 
the  femoral  artery,  and  a  small  septic  wound  of  the  skin  of  a  toe 
was  found. 

We  shall  refer  to  sarcomata  of  the  Ivmphatic  glands  later  on. 

(b)  Aneurisms. — The  diagnosis  of  aneurism  is  easily  made  by  its 
position  in  the  course  of  a  large  vessel,  almost  always  the  femoral 
artery,  and  by  its  pulsation,  as  also  bv  the  vascular  conditions  below 
the  tumour,  and,  finally,  by  its  frequent  traumatic  origin.  Not  every 
pulsating  tumour  is,  however,  an  aneurism,  for  there  are  some  very 
vascular  sarcomata  which  pulsate,  and  over  which  a  distinct  murmur 
is  heard  on  auscultation.  It  is  therefore  necessary  to  employ  every 
expedient  to  verify  the  diagnosis  of  aneurism,  especially  the  com- 
pression of  the  femoral  artery  just  above  the  swelling.  Arterio- 
venous anenrisuis  may  also  occur  in  the  thigh,  but  their  diagnosis 
is  facilitated  by  the  fact  that  their  origin  is  always  traumatic. 

ic)  Muscular  SivelUugs — Angiomata,  tubercular  and  gummatous 
nodules,  herniae  and  osteomata  of  muscle  behave  as  m  the  upper 
limb.  It  may  be  stated,  however,  that  herni^e,  as  well  as  bony 
nodules,  are  mostlv  found  in  the  adductor  muscles  of  riders,  because 
they  are  subject  to  great  strain  ("rider's  bone").  Such  a  bon}^ 
formation  may  also  follow  a  single  injury,  for  instance,  a  muscular 
contusion  due  to  the  kick  of  a  horse.  I  have  also  seen  it  follow 
rupture  of  muscle  through  over-extension. 

There  has  been  much  ccjntroversy  as  to  the  possibility  of  ossifica- 
tion within  a  muscle,  independently  of  injurv  to  the  periosteum  and 
misplacement  thereof.  In  my  opinion  there  is  no  doubt  about  this 
possibility,  although  it  happens  that  in  the  thigh  the  periosteal  origin 
of  such  traumatic  muscular  osteomata  has  been  demonstrated  in  many 
cases. 

We  will  discuss  sarcomata  together  with  tumours  of  the  connective 
tissue. 

id)  Conucciive  Tissue. — These  tumours  consist  of  fibromata  and 
sarcomata.  They  may  arise  from  the  connective  tissue  between 
the  muscles  and  nerves  or  within  them.  A  firm  tumour,  which 
remains  movable  for  years  and  causes  no  disturbance  beyond  its 
size,  is  a  fibroma.  The  more  rapid  the  growth  of  a  tumour,  the 
sooner  it  contracts  adhesions  and  the  more  pain  it  excites,  the  richer 
it  is  in  nucleated  cells,  and  the  more  it  approximates  therefore  to  the 


SWELLINGS   AND   TUMOURS   OF   THE   THIGH  659 

type  of  sarcoma.  As  no  sharp  limitations  can  be  drawn,  even  histo- 
logically, a  positive  diagnosis  cannot  be  made  clinically.  It  is  better 
to  eradicate  the  tumour  before  it  becomes  malignant  than  to  wait  until 
a  positive  diagnosis  is  possible. 

There  are  some  fibromata,  which  at  first  recur  as  such,  but  in 
course  of  time  their  histological  type  approximates  to  that  of  sarcoma. 
It  is  therefore  necessary  to  remove  even  the  most  innocent  tumour 
while  the  patient  is  still  in  good  health. 

The  relations  of  the  tumour  to  the  muscles  may  be  ascertained 
by  examining  it  when  the  muscles  are  relaxed  and  when  they  are 
tense  and  comparing  the  results.  A  neurofibroma  is  diagnosed  by 
its  position  along  the  course  of  a  nerve,  by  its  spindle  or  cylindrical 
shape,  by  the  early  onset  of  neuralgia  and  paraesthesia,  and  occasion- 
ally by  its  multiplicity  or  the  existence  of  similar  tumours  in  other 
portions  of  the  body.  The  risk  of  secondary  malignant  degeneration 
is  always  present  in  these  cases. 


5._SWELLINGS    OF    THE    BONE. 

(1)    OSTEOMA    AND    CHONDROMA. 

If  we  find  close  to  the  lower  epiphyseal  line  a  nodular  bony 
tumour  which  has  existed  for  some  time,  and  which  is  gradually 
growing  away  from  the  joint,  we  have  before  us  the  classical  picture 
of  a  cartilaginous  exostosis  (figs.  397  and  398). 

These  growths  are  congenital  and  arise  from  misplaced  fragments 
of  cartilage  ;  diey  consist  of  bony  tissue  covered  over  by  a  thin  layer 
of  cartilage,  and  they  continue  to  grow  until  the  bone  to  which  they 
belong  has  completed  its  growth.  As  they  are  usually  situated  on  the 
diaphyseal  side  of  the  epiphysis,  they  become  more  and  more  distant 
from  this  line  as  the  bone  grows  in  length.  Sometimes  these  exostoses 
occur  in  separate  attacks,  and  we  may  therefore  find  several  on  the 
same  bone,  at  various  distances  from  the  joint.  Sometimes  they  drag 
with  them  an  extremity  of  the  joint  capsule  with  which  they  have 
contracted  adhesions  in  their  original  position  ;  in  other  cases  they  are 
covered  by  a  mucous  bursa,  quite  independent  of  the  joint — exostosis 
bnrsata.  If  the  diagnosis  still  remains  uncertain  despite  the  considera- 
tion of  all  these  points,  we  should  examine  the  other  epiphyses  of  the 
body  and  probably  find  similar  exostoses  in  other  positions.  Chiara 
found  as  many  as  a  thousand  in  one  person. 

Pure  cartilaginous  tumours,  which  may  also  exist  at  some 
distance  from  the  epiphyseal  line,  form  the  transition  between  these 
innocent  tumours  and  malignant  growths  of  the  femur.  If  they  are 
accessible  to  palpation,  they  present  the  well-known  nodulated  surface 
and  a  consistence  less  hard  than  osteomata.  Central  chondromata, 
are  not,  as  rule,  diagnosed,  until  they  lead  to  spontaneous  fracture. 


66o 


SURGICAL   DISEASES   OF  THE   EXTREMITIES 


(2)    SARCOMATA    AND    ALLIED    TUMOURS. 

We  must  never  diagnose  a  prnnary  malignant  growth  of  the 
femur,  before  assuring  ourselves  that  the  case  is  not  one  of  secondary 
growth.  This  is  more  especially  necessary  in  connection  with  the 
upper  half  of  the  femur,  because  it  is  a  favourite  situation  for  such 
metastases.  Cancer  of  the  breast  is  the  most  likely  original  source,, 
but  the  primary  disease  may  be  cancer  or  sarcoma  anywhere. 

I   have  seen  fracture  in  the  upper  third  of  both  femora  occur  in 

an  aged  female  after  cancer 
of  the  breast.  The  accident 
was  merely  a  slight  slip. 

In  the  absence  of  such 
an  origin,  we  may  assume 
that  a  new  growth  is  present 
— probably  some  variety  of 
sarcoma. 

The  so-called  blood-cysts 
of  file  long  hones,  some  of 
which  were  formerly  termed 
nnenrisnis  of  hone,  are  of  a 
doubtful  nature;  at  any  rate 
they  are  not  obviously  sarco- 
mata. A  spindle-shaped  dis- 
tension of  the  diaphysis, 
looking  like  a  large  beetroot, 
takes  place.  The  cortical 
portion  of  the  bone  is  con- 
verted into  a  thin  shell,  and 
its  interior  is  occupied  by 
trabeculae.  The  structure 
contains  pure  blood.  There 
are  no  tumour  elements 
visible  ;  but  it  may  be  pos- 
sible to  separate  from  the 
internal  surface  a  thin  layer 
of  tissue,  containing  ele- 
ments similar  to  bone  mar- 
row, especially  giant  cells. 
But  whether  the  condition  is  a  tumour,  an  inflammatory  process 
("  ostitis  fibrosa "),  or  the  result  of  an  injury  (an  abnormality  of 
callus)  is  a  subject  of  controversy  (see  also  under  "Leg")-  Attention 
is  usually  first  drawn  to  this  condition  in  the  femur  by  a  spontaneous 
fracture. 

In  other  cases  these  growths  are  rather  of  connective  tissue  nature, 
and  they  cause  bending,  before  spontaneous  fracture  occurs.  Growths 
of  this  kind  have  been  described  as  occurring  in  the  subtrochanteric 
region. 


Fig.  397. — Cartilaginous  exostosis  of  femur. 


SWELLINGS   AND   TUMOURS   OF   THE   THIGH 


66 1 


Putting  aside  these  conditions,  which  are  rarities,  sarcoma  of  the 
femur  presents  itself  either  as  a  diffuse  thickening  of  the  epiphyseal 
region  or  as  a  spindle-shaped  distension  of  the  diaphysis,  which,  later 
on,  becomes  nodular  in  character.  For  the  purpose  of  discussing  the 
differential  diagnosis,  we  must  separate  these  two  forms,  and  we  shall 
begin  with  the  tumours  of  the  epipJiysis. 

(a)  Tumours  of  the  Epiphysis. 

Sarcoma  of  the  upper  end  of  the  epiphysis  is  usually  treated  as  a 
form  of  hip  disease,  or  as  sciatica,  or  even  as  osteomyelitis,  until  the 


Fig.    398. — Cartilaginous   exostosis 
of  the  left  fetiiur. 


Fig.  399. —  Sarcoma  of  the  lower  end  of  the 
femur. 


neck  of  the  femur  suddenly  breaks,  or  the  skiagram  reveals  the 
existence  of  something  which  is  neither  an  ordinary  inflammation  of 
the  hip-joint  nor  a  simple  neuralgia. 

I  once  saw  a  young  man  who  was  of  an  age  when  osteo- 
myelitis is  frequent,  with  a  high  temperature  and  a  rapid  pulse. 
There  was  at  the  upper  end  of  the  thigh  a  soft  elastic  swelling 
which  any  clinical  student  would  have  considered  fluctuating.  I  also 
thought  that  the  swelling  probably  contained  fluid,  and  I  made  an 
exploratory  puncture  in  order  to  decide  between  tubercle  and 
osteomyelitis.     The  examination  of  the  tissue  thus  obtained,  and  the 


662 


SURGICAL   DISEASES   OF   THE    EXTREMITIES 


exploratory  incision  itself  led  to  the  conclusion  that  there  was  a  small 
round-celled  sarcoma  of  gelatinous  appearance  invading  the  pelvis. 
This  was  before  the  time  of  Rontgen  rays  and  the  young  man  rapidly 
succumbed. 

A  vigorous  man  had  kept  his  bed  for  several  months  because  of 
"  sciatica."  On  measuring,  it  was  found  that  there  was  supra- 
trochanteric  shortening,  and  the  skiagram  showed  distension  of  the 

trochanter  by  a 
:  the  neck  of  the 
[        into  it. 

'  Sarcoma  at  the  lower  end  of 

the  femur   is  easily  mistaken,    at 
first,  for  a  tubercular  joint. 

A  middle-aged  man   noticed  a 


growth,     with 
femur   wedged 


L. 


Fig.  400. — Osteomyelitis  of  the  femur,  of  a 
few  months'  duration.  Periosteal  bone  forma- 
tion beginning,     s  =  sequestrum. 


Fig.  401. — Localized  staphylomycosis  of  the 
medulla,     a  =  healthy  side  ;  d  =  diseased  side. 


slight  swelling  about  the  knee,  after  a  blow.  A  very  experienced 
practitioner  made  the  diagnosis  of  tubercular  knee,  and  a  surgeon 
who  was  called  into  consultation  agreed.  Five  years  went  by,  with 
iodoform  injections  and  waiting.  The  knee  continued  to  swell,  but 
the  movements  of  the  joint  remained  free.  Finally,  the  lower  end  of 
the  femur  assumed  the  appearance  of  a  club-shaped  structure,  about 
as  big  as  two  fists.  It  was  evidently  a  case  of  giant-celled  sarcoma, 
covered  by  a  thin  shell  of  bone,  similar  to  the  case  illustrated  in 
fig-  399;  ^vhich  was  also  first  diagnosed  as  tubercle. 


SWELLINGS   AND   TUMOURS   OF   THE   THIGH 


663 


The  main  point  in  diagnosing  these  cases  is  to  locaHze  the  swelhng 
accurately.  In  tubercle  the  capsule  is  thickened,  but  the  underlying 
bone  is  of  normal  dimensions.  The  thickness  of  the  capsule  is  easily 
detected  by  comparing  both  knees  on  palpation,  especially  at  the 
borders.      If   the  whole  region  of   the  knee  appears  to    be   swollen, 


-V 


.1 


i^'* 


Fig.  402. — Osteomyelitis  of  femur,  with  bending  of  the  lower  end  of  the  diaphysis. 


Fig.  403. — Skiagram  of  fig.  402.     S  =  sequestrum. 

although  the  soft  tissues  and  the  capsule  are  free,  we  must  assume 
the  existence  of  a  more  deeply  situated  process — either  a  tumour  of 
the  bone  or  a  chronic  osteomyelitis.  We  may  derive  much  assistance 
from  the  mobility  of  the  joint.  Movements  persist  for  a  long  time 
in  cases  of  tumour,  but  they  are  quickly  interfered  with  by  tubercle, 
although    some    tubercular    knees    retain    their    mobility    for    5^ears. 


664 


SURGICAL   DISEASES   OF   THE   EXTREMITIES 


Thickening  of  the  capsule  which  decides  the   diagnosis  is,  however, 
always  present  in  these  cases. 

Chronic  osteomyelitis  is  more  likely  to  be  a  source  of  error 
than  tubercle.  If  the  growth  is  characterized  by  sudden  exacerbations, 
and  especially  if  there  are  periods  of  deep  and  throbbing  pain  in  the 
bone,  accompanied  by  acute  transitory  effusion  into  the  joint,  the 
case  is  probably  chronic  osteomyelitis.  If  the  disease  has  persisted 
for  many  years,  we  must  assume  that  an  inflammatory  process  exists. 
In  the  case  just  quoted  there  was  a  duration  of  live  years  j  but  this  is 
the  extreme  limit  which  is  consistent  with  the  diagnosis  of  sarcoma. 
As  a  rule,  the  course  of  these  tumours  permits  the  diagnosis  to  be 
made  verv  much  earlier  than  this. 

The  appearance  of  a  definite  subcu- 
taneous venous  nehvork  is  another  sign 
which  should  be  mentioned  as  an  indica- 
tion that  the  deepiv  situated  large  veins 
are  compressed.  This  rareh'  occurs  in 
tubercle,  but  may  take  place  in  osteo- 
myelitis if  thick  periosteal  indurations  form. 
It  occurs  most  frequently,  however,  in 
connection  with  malignant  growths. 


Fig.   404. — Fracture  of  healthy 
shaft  of  femur. 


(b)  Tumours  of  the  Diaphysis. 

Ttimours  of  the  diaphvsis  are  more 
difficult  to  diagnose  than  those  of  the 
epiphysis,  because  they  are  less  accessible 
to  palpation,  and  because  the  characteristic 
changes  in  the  knee-joint  are  less  in 
evidence.  Otherwise  the  rules  applicable 
to  the  epiphysis  apply  here  also.  It  should 
be  especially  noted  that  osteomyelitis  has 
a  much  greater  tendency  than  sarcoma  to 
travel  along  the  whole  extent  of  the  shaft  of  the  femur.  Cases 
wherein  the  tumour  is  sharply  delimited  from  the  shaft  of  the  femur 
are  therefore  easy  to  recognize;  difficulty  of  diagnosis  arises  in  con- 
nection wdth  the  more  diffuse,  spindle-shaped  sarcomata. 

Tw^o  examples  will  illustrate  how  errors  of  diagnosis  may  be  caused 
by  the  unusual  behaviour  of  the  staphylococcus. 

A  man,  aged  32,  otherwise  in  good  health,  had  been  suffering  pain 
in  his  right  thigh  for  a  few  weeks.  The  pain  did  not  come  on 
suddenly,  and  the  patient  was  not  conscious  of  any  antecedent  febrile 
disease,  nor  had  there  been  any  previous  injury.  For  some  time  the 
patient  thought  he  had  rheumatism,  but  eventually  consulted  a  doctor, 
who  found  a  slight  thickening  in  the  middle  of  the  femur,  and  thought 
of    sarcoma.      On   palpation,  however,   the    structure  was    somewhat 


SWELLINGS   AND   TUMOURS   OF   THE   THIGH 


66: 


more  tender  than  one  would  expect  in  the  case  of  a  tumour.  The 
X-rays  revealed  a  slight  thickening  of  the  cortex,  indicated  by  a 
sharply  defined  shadow  (fig.  401).  this  pointed  to  an  inflammatory 
condition.  As  tubercle  practically  never  occurs  in  the  shaft  of  the 
femur,  the  diagnosis  was  evidently  a  very  mild  form  of  "acute  osteo- 
myelitis," or  rather  a  chronic  staphylomycosis,  which  better  describes 
the  actual  condition  present.  But  even  this  designation  was  ex- 
posed to  the  risk  of  error,  because  an  identical  clinical  picture  can 
be  produced  by  the  streptococcus  and  other  pus  organisms.  The 
operation,  however,  showed  that  staphylomycosis  was  correct,  because 
the  small  amount  of  pus  which  was  found  yielded  the  Staphylococcus 
aureus. 


Fig.  405. — Spontaneous  fracture  in  myelogenous  sarcoma. 


I  saw  the  other  case  as  a  student  in  Kocher's  clinic.  It  was  subse- 
quently recorded  by  Kocher  and  Tavel  in  their  work  on  staphylomy- 
coses. The  tumour  was  situated  in  the  lower  portion  of  the  femur, 
and  completely  simulated  a  sarcoma.  It  contained  a  brownish  yellow 
granulation-like  tissue,  under  a  thick  indurated  sheath.  A  piece 
of  the  tissue  was  examined  by  a  competent  histologist  during  the 
operation,  and  declared  to  be  sarcoma.  Amputation  would  have  been 
resorted  to  had  not  a  small  sequestrum  which  was  found  deep  down, 
indicated  another  diagnosis.  Inoculation  on  a  nutrient  medium 
yielded  the  Staphylococcus  aureus,  and  the  leg  was  saved. 

Spontaneous  bending  of  the  bone  sometimes  occurs  as  a  result  of 
osteomyelitis,  and  is  due  to  the  traction  of  the  flexors  of  the  knee  on 


666 


SURGICAL   DISEASES   OF   THE    EXTREMITIES 


the  partially  destroyed  diaphysis.  Figs.  402  and  403  illustrate  the 
consequent  typical  deformity.  If  there  is  a  fistula,  as  there  was  in 
this  case,  the  diagnosis  cannot  be  missed. 

Sometimes — but  not  always — the  skiagram  differentiates  between 
osteo-myelitis  and  sarcoma.  The  following  applies  both  to  the 
epiphysis  and  the  diaphysis. 

The  skiagram  of  osteomyelitis  shows  either  (i)  a  normal  edge  to 
the  bone;    or   (2)  sharply  defined,   often    clearly  laminated  deposits 

(figs.  400  and  401),  gradually 
shelving  away  on  both  sides. 
The  former  appearance  means 
that  the  process  is  comparatively 
recent,  and  that  the  palpable 
swelling  depends  upon  peri- 
ostitis without  new  bone  forma- 
tion. The  latter  appearance 
means  that  the  process  is  some- 
what old,  and  has  led  to  peri- 
osteal bone  formation.  The 
limits  of  the  sequestrum  (figs. 
400  and  403)  may  often  be 
recognized  at  this  stage.  The 
older  the  process,  the  less  clear 
is  the  lamination,  so  that  finally 
the  appearance  is  that  of  a  diffuse 
spindle  -  shaped  or  cylindrical 
thickening  of  the  bone  (partially 
in  fig.  402), 

In  myelogenous  sarcoma  the 
borders  of  the  femur  are  equally 
enlarged,  or  on  one  side  only. 
The  cortex  of  the  distended 
portion  of  the  bone  is  greatly 
thinned — it  may  be  as  thin  as 
paper.  The  osseous  structure  is  obliterated,  and  light  patches  appear 
in  the  bone.  "  Spontaneous  fractures  caused  by  malignant  growths  are 
remarkable,  as  seen  in  the  skiagram,  by  the  rounded  ends  of  the  frag- 
ments or  by  the  peculiar  erosion  of  the  cortex  {cf.  figs.  405  and  406). 
Periosteal  sarcoma  appears  as  a  deposit,  on  the  normal  or  more  or 
less  deeply  eroded  bone,  and  casts  a  light  shadow.  Sometimes 
pronounced  deposits  of  periosteal  bone  appear,  which  make  the 
picture  very  similar  to  that  of  osteomyelitis. 


Fig.  406. — Spontaneous  fracture  in  a  meta- 
stasis of  cancer  of  breast. 


INJURIES    IN   THE    VICINITY    OF    THE    KNEE-JOINT 


667 


CHAPTER  XCVII. 
INJURIES  IN  THE  VICINITY  OF  THE  KNEE-JOINT. 

In  falling  forward  we  instinctively  bend  the  upper  part  of  the 
body  backwards,  in  order  to  protect  it — and  especially  the  face  — from 
damage.  The  force  of  the  fall  is  therefore  borne  by  the  knee,  and 
by  the  hands  which  are  extended  at  the  same  time.  This  explains  the 
great  frequency  of  injuries  to  the  knee-joint. 

(i)  If  we  find  a  swelling  in  front  of  the  knee,  after  a  fall  directly 
upon  the  joint,  and  if  on  pal- 
pating the  patellar  region  a 
cushion-like  feeling  is  obtained, 
there  is  an  efFusion  into  the 
prepatellar  bursa.  The  more 
quickly  the  swelling  develops 
after  the  fall,  the  more  likely 
is  it  to  contain  blood  ;  the 
longer  its  development  is  de- 
layed, the  more  likely  is  it  to  be 
a  serous  effusion,  i.e.,  prepatellar 
bursitis. 

(2)   It   is    more    frequent   to 
find    some     intei'ference     with 
movement  —  limitation      of 
flexion  —  and    a    swelling   not 
localized   to    the  front   of    the 
patella,     but     around     it,    the 
groove  on  either  side  of  it  being 
obliterated    (fig.    407).     At   the 
same   time   a  transverse  swell- 
ing appears  above  the  patella, 
especially  when  the  quadriceps 
tendon  is  relaxed.     Sometimes  the  obliterated  lateral  grooves  become 
•conveited  into  genuine  swellings,  and  the  superior  transverse  swelling 
increases  in  size.     The  patella  is  raised,  and  although  it  may  be  pressed 
back  against  the   condyles  of  the  femur,    it  instantaneously   returns 
to  its  former  level— so-called  "riding"  of  the  patella.     The  French 
term  "  ballottement  "  is,  however,  more  accurate.     Such  a  condition 
indicates  an  eftusion  within  the  joint;  whether  it  is  more  of  a  serous 
■or  of  a  haemorrhagic    character,    depends    upon    the  rapidity   of  its 
development.     If  the  skin  presents  abrasions,  in  evidence  of  the  direct 
effect  of  the  force,   and  if  the  parts    upon  which    the    force    fell— the 
43 


Fig.  407. — Effusion  into  the  joint  in  sprained 
knee. 


668 


SURGICAL   DISEASES    OF   THE   EXTREMITIES 


patella  and  tuberosities  of  the  tibia — are  tender,  while  the  region  of  the 
lateral  ligaments  is  free,  the  diagnosis  is  contusion  of  the  knee-joint. 

If  the  injury  was  indirect,  taking  the  form  of  excessive  adduction 
or  abduction  or  rotatory  movement,  we  must  assume  the  existence  of 
a  sprain,  as  long  as  the  symptoms  are  limited  to  effusion  and  inter-, 
ference  with  movement. 

The  manner  in  which  the  accident  happened  often  makes  it 
impossible  for  us  to  distinguish  between  contusion  and  sprain. 
The  patient,  for  example,  has  fallen  down,  and  lights  upon  his 
leg  in  a  constrained  attitude — more  or  less  in  the  "  tailor's  attitude."' 
He  may  have  sustained  a  contusion  or  a  sprain.  The  absence 
of  cutaneous  abrasions  does  not  necessarily  exclude  the  latter. 
We  therefore  adopt  another  sign  to  differentiate  between  these  two 
injuries  :    the  localization  of  the  tenderness  to  pressure.      We  have 

already  seen  where  this  is 
in  cases  of  contusion.  In 
sprains,  however,  it  is  found 
in  the  vicinity  of  the  lateral 
ligaments,  because  the  main 
force  of  the  injury  is  situated 
there.  Sometimes  the  ten- 
derness exists  over  both 
lateral  ligaments,  or  over 
their  attachments  to  the 
femur  and  tibia  ;  sometimes 
only  over  one  ligament — 
generally  the  inner. 

It  may  be  objected  that 
these  points  are  unnecessary 
refinements,  seeing  that  the 
treatment  is  identical.  It 
should,  however,  be  remem- 
bered that  contusions  and  sprains  have  their  special  complications, 
which  will  be  indistinguishable  clinically  unless  the  nature  of  the 
original  injury  is  recognized.  In  both  cases,  it  sometimes  happens 
that  the  trouble  does  not  subside  in  the  usual  way.  Creaking  sounds,, 
which  are  often  audible  at  a  distance,  may  occur  in  the  joint  ;  sudden 
severe  pains  interfering  with  movements,  or  a  rapidly  developing 
effusion  may  arise — conditions  which  were  previously  described 
by  the  term  "  derangennent  interne."  This  vague  diagnosis  was 
rendered  necessary  by  the  vague  knowledge  of  the  actual  conditions 
within  the  joint,  in  pre-antiseptic  days,  when  operation  was  justifiably 
avoided.  But  to-day  we  possess  data  which  enable  a  more  accurate 
diagnosis   to   be  made.     If  the  original   injury  was  a  contusion,  the 


Fig.  408. — Fracture  of  cartilage  over  median 
condyle  of  femur  (x). 


INJURIES    IN   THE   VICINITY   OF   THE   KNEE-JOINT 


669 


internal  lesion  consists  of  the  fracture  of  the  cartilage  of  one  of  the 
condyles  of  the  femur — generally  the  median.  The  detached  piece 
has  hyaline  cartilage  on  the  one  side,  and  more  or  less  altered  bone  on 
the  other  side.  The  depression,  covered  by  a  smooth  cartilage-like 
scar,  may  be  found,  years  afterwards,  on  the  condyle. 

It  is  obvious  that  these  fractures  are  more  likely  to  happen  if  the 
cartilage  or  bone  be  diseased,  i.e.,  in  arthritis  deformans.  As  the 
injury  which  causes  these  detachments  may  be  very  slight,  even  in 
young  people,  Konig  assumes  the  existence  of  an  ostco-chondritis 
dissecans  as  a  predisposing  cause — an  assumption  which  has,  however, 

met  with  considerable  ob- 
jection. We  cannot  enter 
into  the  question  here. 
The  main  thing  is  to  recog- 
nize the  injury,  what- 
ever be  its  pathological 
antecedent. 

The  principal  evidence 


Fig.  409.- 


-Knee  joint  with  two  free  foreign  bodies 
{a  and  li).     Patient  aged  38. 


Fig.  410. — Sesanaoid  {s)  bone  in 
popliteal  space. 


of  the  presence  of  a  foreign  body  in  the  joint  is  derived  from  actually 
feeling  it,  and  from  an  accurate  knowledge  of  the  direction  of  the 
injury.  Repeated  examinations  may  be  required  in  order  to  palpate 
the  foreign  body,  and  even  then  one  may  fail.  X-ray  examination  is 
conclusive,  if  some  bone  is  attached  to  the  cartilage,  as  is  usually  the 
case. 

A  sesamoid  bone  (fig.  410)  m  the  flexor  tendons  of  the  knee  must 
not  be  mistaken  for  a  foreign  body  in  the  joint. 

There  are  some  foreign  bodies  in  joints  which  do  not  arise  from 
injury.     Cartilaginous  proliferations  in  certain  forms  of  arthritis  may 


670 


SURGICAL   DISEASES    OF  THE    EXTREMITIES 


be  broken  off  quite  unknown  to  the  patient.     Cretinisiii,  or  at  any 
rate  hvpothyroidisiu,  plays  a  definite  role  in  this  connection. 

If  the  injury  was  a  sprain  (generally  an  eversion  of  the  femur  on 
the  fixed  tibia),  the  "derangement  interne"  consists  of  the  detach- 
ment and  displacement  and  temporary  "locking"  of  a  semilunar 
cartilage,  especially  the  internal.  Besides  the  characteristic  pain 
associated  with  this  lesion,  there  are  two  other  symptoms  which  lead 
to  the  diagnosis  :  (i)  Pain  on  pressure  over  the  attachment  of  the 
corresponding  lateral  ligament,  or  over  the  attachment  of  the  semi- 
lunar cartilage  to  the  tibia  ;    and    (2)  the  extrusion  of  the  cartilage 

from  the  joint  cavity 
on  extension  of  the 
limb — a  somewhat  rare 
symptom. 


Fig.    411. — Sprained  knee   with   detachment  of  the 
insertion  of  crucial  ligament  into  the  libia  (x). 


Fig.  412. — Fragment  detached 
from  internal  condyle  of  femur. 


The  former  symptom  is  only  found  in  comparatively  recent  cases, 
and  the  latter  is  frequently  entirely  absent,  so  that  we  often  have  to 
rely  exclusively  on  the  history.  The  differential  diagnosis  between 
fracture  of  the  articular  cartilage  and  laceration  of  the  semilunar 
cartilage  may  also  be  suggested  by  the  frequency  of  the  attacks. 
If  these  are  infrequent,  but  accompanied  by  very  severe  disturbances 
within  the  joint,  the  case  is  probably  one  of  fracture  of  the  cartilage 
over  one  of  the  condyles.  If  the  attacks  are  frequently  repeated, 
and  if  loud  grating  occurs  on  any  extensive  movement,  the  case  is 
probably  a  laceration  of  the  semilunar  cartilage. 
.     It  should  be  mentioned  that  in   Earth's  opinion  fractures  of   the 


LMIURIES    IN   THE    VICINITY    OF   THE    KNEE-JOINT 


671 


cartilage  over  the  femoral  condyles  may  also  be  caused  by  sprains. 
He  assumes  that  a  piece  of  cartilage  may  be  torn  off  by  means  of  one 
of  the  crucial  ligaments.  This,  however,  would  be  a  rare  contingency 
which  does  not  invalidate  what  has  already  been  said.  Fig.  411 
shows  that  the  attachments  of  the  crucial  ligaments  to  the  bone  may 
be  torn  off  in  cases  of  severe  sprain. 

Stieda  has  described  a  lamella  of  bone  at  the  upper  end  of  the 
internal  lateral  ligament  as  a  late  sequela  of  sprains. 

It  is  not  clear  whether  this  is  due  to  a  detachment  of  periosteum 
and  bone  at  the  moment  of  the  injury,  or  whether  it  is  due  to 
secondary  bone  formation  in  the  torn  ligament.  Both  causes  may 
possibly  contribute.  I  have  observed  the  entire  disappearance  of  this 
lamella  within  a  few  months. 


Fig.   413. — Normal  spine  of  tibia  in  a 
young  person. 


Fig.  414. — Detachment  of  spine  of  tibia. 


To  return  to  the  recently  inflicted  injury.  A  patient  suffering 
from  a  sprain  or  contusion  can  lift  his  leg  in  a  position  of  extension, 
although  it  may  cause  pain.  If  this  is  impossible,  we  must  conclude 
that  there  has  been  some  injury  either  to  the  extensor  apparatus  or  to 
the  bone  itself. 

(3)  We  can  tell  in  a  moment  whether  there  is  shortening,  or  pain 
on  pressure  on  the  axis  of  the  limb,  and  thus  decide  as  to  fracture 
in  the  continuity  of  the  bone.  In  the  absence  of  this,  the  only  other 
possible  condition  is  laceration  of  the  extensor  apparatus.  This  may 
occur  m  one  of  three  situations  :  (i)  In  the  quadriceps  tendon  above 
the  patella;  (2)  in  the  patella  itself;  and  (3)  below  it,  i.e.,  in  the 
ligamentum  patellae.  Palpation  of  the  region  involved  will  at  once 
give  an  approximate  idea  of  the  situation  of  the  injury.     Laceration 


6/2 


SURGICAL   DISEASES   OF   THE   EXTREMITIES 


Fig.  415.- -Transverse  fracture  of  patella. 


Fig.  416.  —  Comminuted  fracture  of  patella. 


Fig.  417. — Supracondylar  fracture,  seen  from  the  FiG.  418.  —  Supracondylar  fracture,  seen  from   the 
fiont,   with  typical  displacement.      C.e.  =  external       side.    Typical  displacement  of  lower  fragment. 
condyle.    C.i.  =  internal  condyle.     Upper  fragment 
displaced  forwards  and  outw-ards. 


IXJURIES    IX    THE    VICIXITY    OF   THE    KXEE-JOIXT 


673 


Fig.    419.  —  Supracondylar  fracture. 
(From  a  case  of  cretinism.) 


Fig.  420. — Fracture    of   external    tuberosity    of   the    tibia. 
i^Fragments  torn  and  broken  off  the  femoral  condyles. 


Fig.    421. — Condylar   fracture.     {Post-morlem 
preparation.)     Y-shaped  fracture. 


Fig.  422.— Fracture  of  the  tibia,  below 
tuberosities. 


674 


SURGICAL   DISEASES   OF   THE   EXTREMITIES 


of  the  quadriceps  tendon,  the  rarest  of  these  injuries,  produces  an 
easily  palpable  and  even  visible  hollow  above  the  patella.  This  is 
especially  striking  if  the  upper  end  of  the  tendon  rolls  up,  and  thus 
appears  to  be  thickened. 

Detachment  of  the  ligamentum  patellae  close  to  the  knee-cap, 
with  some  bone  substance  adherent  to  it,  is  of  more  frequent 
occurrence.  This  injury  is  also 
easily  detected  by  the  finger.  But 
fracture  of  the  patella  is  still 
more  frequent,  and  the  results 
of  palpation  are  so  clear  that  a 
mistake  is  scarcely  conceivable. 

The  precise  manner  in  which 
fracture  of  the  patella  occurs  has 
been  a  subject  of  much  contro- 
versy. It  has  been  stated  that 
the  simple  transverse  fracture 
(fig.  415)  is  indirect,  and  caused 
by  muscular  contraction,  and 
that  the  Y-shaped  or  radiate  frac- 


FlG.  423. — Detachment  of  head  of  fibula. 


Fig.  424. — Dislocation  of  the  knee.  Promin- 
ence of  the  internal  condyle.  Ci.,  caught  by 
the  buttonhole  mechanism  ;   P.,  patella. 


ture  (fig.  416)  is  caused  by  direct  force,  i.e.,  by  falling  on  the  patella. 
Four-fifths  of  the  cases  of  fracture  of  the  patella  were  attributed 
to  muscular  action,  whereas,  as  a  matter  of  fact,  recent  careful 
observations  show  that  the  proportion  is  exactly  the  reverse. 

Schlatter  describes  cases  wherein  the  spine  of  the  tibia  has  been 
torn  off  or  broken  off  at  the  epiphyseal  line  in  young  persons  (fig.  414). 


INJURIES    IX    THE    VICIXITY    OF   THE    KXEE-JOIXT 


67: 


One  must,  however,  guard  against  mistaking  the  normal  hne  of  the 
epiphysis,  however  unusual  it  may  look,  for  the  result  of  some  trauma 
(fig.  413).  In  most  cases  the  pains  are  due  to  tearing  and  not  to  gross 
anatomical  changes. 

(4)  If,  on  the  contrary,  there  is  pain  on  axial  pressure  with  shorten- 
ing, however  slight,  combined  with  severe  haemorrhagic  effusion  into 
the  knee-joint,  we  conclude  that  the  lesion  is  not  in  the  extensor 
apparatus,  but  that  it  is  located  in  the  continuity  of  the  limb,  i.e.,  either 
a  fracture  of  the  lower  end  of  the  femur  or  the  upper  end  of  the  tibia. 


Fig.  425. — Skiagram  of  same  case.     Attachments  of  crucial  ligaments  to  tibia,  torn  off. 

These  fractures  are  classified  as  supracondylar,  diacondylar  (in 
the  epiphyseal  line  of  the  femur),  fractures  of  the  external  and  internal 
condyle,  combined  Y-  and  T-shaped  fractures,  and  infracondylar 
(tibia).  These  various  forms,  however,  are  less  subject  to  rule  than 
the  corresponding  fractures  at  the  elbow. 

Supracondylar  fracture  does  not  involve  the  joint  directly,  but 
it  often  happens  that  the  upper  fragment,  which  is  usually  displaced 


676  SURGICAL    DISEASES    OF    THE    EXTREMITIES 

forwards  and  outwards,  penetrates  the  joint  between  the  lower 
fragment  and  the  patella.  The  joint  cavity  is  thus  opened  up  and 
participates  in  the  haematoma.  The  usual  course  of  the  lines  of 
fracture  is  seen   figs.  417-419. 

Fig.  419  represents  the  case  of  a  dwarfed  cretin,  whose  femora  had, 
for  a  whole  year,  undergone  subperiosteal  bending  at  the  same 
situations.  Hypothyroidism  is  one  of  the  chief  causes  of  diminished 
bone  stability.  I  was  once  consulted  for  a  patient  with  thyroid 
inadequacy  who  had  just  sustained  his  twenty-second  fracture. 

If  the  haemorrhagic  effusion  is  considerable,  an  accurate  diagnosis 
cannot  be  made  without  an  X-ray  examination,  which  should  always 
be  made  in  two  directions  at  right  angles  to  each  other. 

Diacondylar  fracture,  occurring  as  a  separation  of  the  epiphysis, 
is  a  very  rare  event,  and  if  the  displacement  is  slight  may  be  mistaken 
for  a  sprain.  If  the  displacement  is  considerable,  or  if  false  mobility 
exists,  the  diagnosis  is  based  upon  the  facts  of  lateral  displaceability 
and  the  absence  of  any  interruption  of  continuity  above  the  joint 
line. 

Fracture  of  the  condyles  in  their  various  combinations  are 
recognized  by  the  mobility  of  one  or  both  detached  condyles,  on 
the  shaft  of  the  femur,  and  by  the  varus  or  valgus  position  assumed 
by  the  joint.  Y-  and  T-shaped  fractures  arise  from  the  shaft  of  the 
femur  being  driven  in,  like  a  wedge,  between  the  condyles  (fig.  421). 
Details  are  accurately  obtained  by  a  skiagram,  which  is  preferable  to 
the  otherwise  unavoidable  examination  under  an  anjesthetic. 

Similar  fractures  occur  in  the  tibia  (fig.  422);  the  infracondylar 
variety  being  the  most  frequent. 

Detachment  of  the  head  of  the  fibula,  which  is  a  very  characteristic 
but  rare  fracture,  should  be  mentioned  here  (fig.  423). 

Dislocations  of  the  knee-joint  and  of  the  patella  are  still  more 
rare.  Dislocations  of  iJic  knee — both  congenital  and  traumatic — have 
been  seen  in  all  directions,  forwards,  backwards,  downwards  and 
outwards.  Their  appearances  are  so  remarkable  that  it  is  unnecessary 
to  discuss  their  differential  diagnosis.  But  incomplete  lateral  dis- 
locations require  very  careful  palpation.  The  button-hole  mechanism, 
whereby  one  of  the  condyles  becomes  ''caught,"  as  first  described  by 
Iselin,  is  worth  noting.  It  is  illustrated  in  fig.  424. 
I J  Displacements  of  the  patella,  which  are  usually  external,  are 
diagnosed  by  careful  palpation.  This  bone  is  quite  superficial,  and 
there  is  no  difficulty  in  detecting  whether  it  is  displaced  outwards  or 
inwards,  or  perched  on  its  edge.  Two  cases  of  vertical  torsion  through 
an  angle  of  180°  have  been  described,  but  the  diagnosis  of  this 
condition  would  be  more  difficult. 


ACUTE   INFLAMMATORY    DISEASES    OF   KXEE-JOIiNT  677 

CHAPTER    XCVIII. 

ACUTE   INFLAMMATORY   DISEASES    OF   KNEE- 
JOINT. 

Acute  inflammation  of  the  knee-jomt  rarely  presents  any  diagnostic 
difficulty.  The  first  point  to  settle  is,  that  the  disease  is  really  in  the 
joint.  Superficial  examination  may  lead  to  a  diagnosis  of  suppuration 
within  the  knee,  when  the  condition  is  really  one  of  prepatellar 
phlegmonous  bursitis,  if,  as  frequently  happens,  many  ounces  of  pus 
are  present  and  the  whole  knee  appears  to  be  swollen  in  an  unshapely 
manner.  But  the  distinction  is  easy  if  the  examination  is  careful. 
The  swelling  is  in  front  of  the  patella  in  bursitis  ;  in  a  suppurating 
knee,  however,  the  prepatellar  region  is  rather  flattened  out,  and  the 
patella  itself  can  be  felt  just  under  the  skin.  In  bursitis  the  popliteal 
space  is  free,  whereas,  in  acute  arthritis  of  the  knee,  it  is  painful  on 
pressure. 

In  considering  the  knee-joint  itself,  we  must  be  quite  clear  as  to 
the  elements  which  such  an  inflammation  may  comprise,  i.e., 
(i)  effusion  of  fluid,  (2)  swelling  of  the  capsule,  (3)  bony  and 
cartilaginous  changes.  Often  only  one  of  these  signs  is  present,  but 
frequently  there  are  two,  and  sometimes  all  three. 

Effusion  into  tlie  joint  is  recognized  by  the  filling  out  of  the  fossae 
on  either  side  of  the  patella,  and  by  the  distension  of  the  supra- 
patellar bursa.  If  the  eftusion  is  considerable  the  phenomenon  of 
'•'riding  of  the  patella"  appears.  If  the  capsule  becomes  lax  after  the 
subsidence  of  the  eftusion,  the  knee-cap  can  be  displaced,  to  a 
remarkable  extent,  in  all  directions. 

In  order  to  detect  any  slight  degree  of  swelling  of  the  capsule,  it  is 
necessary  to  compare  its  fold  of  reflection  on  both  knees.  Normally 
this   can  just  be  felt  if  the  patient  is  not  too  fat. 

Involvement  of  tlie  bone  is  often  difficult  to  recognize,  unless  some 
striking  change  in  shape  is  present,  A  tender  area,  which  is  sharply 
limited,  and  not  at  the  situation  where  the  capsule  is  reflected, 
indicates  a  lesion  in  the  bone. 

Views  differ  as  to  the  significance  of  the  pain  on  axial  pressure. 
This  is  usually  held  to  be  a  sign  of  bone  disease,  but  this  cannot  be 
correct  if,  as  Lennander  assumes,  the  bone  itself  is  insensitive  and 
only  the  periosteum  possesses  sensation. 

The  etiology  of  acute  inflammation  of  the  knee  is  the  same  as 
that  of  acute  arthritis  elsewhere.  We  have  already  discussed  this  in 
full  in  connection  with  the  shoulder-joint,  and  will  only  refer  here 
to  a  few  characteristic  conditions. 

If  we  are  consulted  about  a  case  of  acute  eft'usion  in  a  joint,  we 


678  SURGICAL    DISEASES   OF   THE    EXTREMITIES 

must  first  inquire  whether  there  has  been  any  recent  injury.  In  the 
absence  of  such  a  cause  we  must  inquire  about  former  injuries,  and 
previous  attacks  of  sudden  joint  swelhng.  If  we  ascertain  that 
such  attacks  have  occurred  and  that  they  have  been  occasionally 
accompanied  by  severe  pain  which  prevented  any  further  movement,, 
we  should  think  of  a  foreign  body  in  the  joint  and  locking  of  a  semi- 
lunar cartilage.  If  necessary,  the  differential  diagnosis  must  be  made 
by  means  of  X-rays  (fig.  409).  If  the  effusion  occurs  periodicallyr 
without  the  signs  of  a  foreign  body,  we  should  think  of  the  rare  cases 
of  intermittent  hydrops  of  the  knee,  probably  of  nervous  origin. 

In  the  absence  of  any  injury  or  any  previous  attacks  of  a  similar 
character,  we  should  conclude  that  the  case  is  of  an  infective  nature^ 
if  the  effusion  has  come  on  within  a  few  days  with  severe  pain, 
tension  and  pyrexia.  If  the  patient  is  a  young  man  and  the  knee 
is  the  only  joint  affected,  we  should  ask  him  sotto  voce  when  he  had 
gonovrliaa.  He  will  rarely  deny  the  impeachment,  but  may  ask  that 
it  should  be  treated  as  rheumatism,  out  of  regard  "for  the  old- 
fashioned  ideas  of  his  parents." 

We  should  make  the  same  diagnosis  if  a  young  woman  has 
"  caught  cold"  on  her  honeymoon. 

Secondary  inflammation  of  the  knee  has  been  observed  in  infants 
with  gonorrhoeal  ophthalmia,  as  also  in  little  girls  with  gonorrhoea. 

Insured  persons  will  attribute  it  to  an  accident.  In  some  cases 
this  will  be  pure  invention,  but  it  is  quite  conceivable  that  a  slight 
sprain  may  afford  the  gonococcus  the  opportunity  of  attacking  a 
joint,  if  the  organism  already  exists  in  the  body. 

An  acute  inflammation  of  the  knee-joint  after  a  confinement  or  a 
septic  abortion,  presents  difficulties  of  a  therapeutic  rather  than  of 
a  diagnostic  nature. 

Acute  arthritis  occurs  more  frequently  in  the  knee  than  in  other 
joints,  as  a  result  of  direct  iiijnry,  varying  from  a  needleprick — the 
needle  remaining  in  the  capsule — to  the  cut  of  a  hatchet.  This  is 
not  always  followed  by  acute  suppm-ative  inflammation  with  great 
swelling  and  high  fever.  The  knee  more  frequently  swells  up 
gradually  in  the  course  of  a  few  days,  the  fever  is  slight  and  the 
periarticular  changes  are  trivial.  The  shape  of  the  distended  articular 
space  is  very  clearly  discernible  through  the  soft  parts.  As  the 
symptoms  are  so  mild,  nothing  but  a  purely  serous  exudation  is 
expected ;  but  exploratory  puncture  shows  that  some  turbidity  already 
exists  owing  to  fibrin  and  pus  cells.  If  the  case  is  treated  without 
delay  in  an  appropriate  manner  the  knee  will  be  saved,  but  if  delay 
is  incurred  stift'ness  will  result. 

In  growing  children  every  case  of  acute  inflammation  of  the  knee 
should  suggest  the  possibility  of  acute  osteomyelitis  of  one  of  the 
adjacent    bones.      An    articular    eft'usion,    sometimes    purely   serous, 


CHRONIC   DISEASES    OF   THE    KNEE  679 

is    often    the    only    symptom    of   a    localized    diseased   area    in    an 
epiphysis. 

Diagnostic  interest  may  also  attach  to  the  late  sequclce  oj  acute 
iiifiaininatory  knee-joints.  If,  despite  extensive  incision,  the  tempera- 
ture remains  high  and  the  neighbourhood  of  the  joint  remains 
swollen,  we  must  assume  that  periarticular  abscesses  have  developed, 
which  are  most  frequently  found  under  the  extensor  muscles  and  the 
patella.  Sometimes  the  joint  continues  to  suppurate  despite  multiple 
mcisions,  and  the  temperature  persists  at  100*5°  although  no  periar- 
ticular abscesses  can  be  demonstrated.  X-rays  will  show  that  the 
interval  between  the  femur  and  tibia  is  abnormally  narrow,  owing  to 
more  or  less  destruction  of  the  cartilage.  On  exposing  the  joint  the 
cartilage  will  be  found  to  be  eroded,  the  underlying  bone  more  or 
less  destroyed,  and  in  young  people  the  epiphysis  may  have  formed 
a  sequestrum.  In  other  cases  the  joint  itself  may  have  undergone 
little  change,  but  the  adjacent  metaphysis  may  be  involved,  and  a 
sequestrum  may  even  have  formed. 


CHAPTER   XCIX. 
CHRONIC    DISEASES    OF    THE    KNEE. 

There  is  no  joint  which  varies  so  much  as  the  knee  in  appearance 
as  a  result  of  chronic  inflammation  from  one  and  the  same  cause. 
Great  caution  must  be  exercised  in  diagnosing  the  cause  from  the 
anatomical  conditions  present. 

Thus  simple  hydrops  of  the  knee  may  exist  in  chronic  traumatic 
inflammation,  in  tubercle,  or  in  neuropathic  disease  of  the  joint; 
ankylosis  may  exist  in  chronic  articular  rheumatism,  and  in 
tubercle,  &c. 

A  chronically  inflamed  knee  may  present  three  essentially  different 
conditions,  each  one  of  which  possesses  its  own  problems  of 
differential  diagnosis  : — 

(i)  Chronic  articular  eft'usion. 

(2)  Thickening  of  the  capsule,  including  the  synovial  membrane. 

(3)  Rigidity  of  the  joint. 

(1)   CHRONIC  ARTICULAR  EFFUSION. 

We  have  already  studied,  in  connection  with  acute  traumatic 
effusions,  how^  to  recognize  an  articular  effusion.  Chronic  effusions, 
however,  last  longer  and  attain  a  larger  size,  though  their  degree  of 
tension  is  not  so  great. 


680  SURGICAL   DISEASES    OF    THE    EXTREMITIES 

Certain  articular  effusions  were  previously  termed  idiopatliic.  We 
now  know,  however,  that,  apart  from  very  rare  intermittent  effusions 
due  to  nervous  disturbances,  that  there  is  no  such  variety.  The  more 
careful  the  history  is  taken,  and  the  more  accurate  the  examination, 
the  more  certain  is  some  cause  to  be  discovered. 

{a)  The  diagnosis  is  usually  chronic  articular  rheumatism,  if 
several  joints  are  affected  simultaneously  or  in  rapid  sequence,  and  the 
remarks  already  made  on  this  malady,  when  dealing  with  diseases  of 
the  shoulder,  should  be  recalled.  In  the  latter,  the  most  frequent 
varieties  are  the  adhesive  and  the  destructive  caries  sicca,  whereas  in 
the  knee  exudative  processes  predominate.  In  the  neuropathic  forms 
there  is  a  great  tendency  to  proliferative  processes.  The  diagnosis  of 
rheumatism  is  often  merely  a  refuge  of  ignorance.  It  should  never 
be  made  until  all  other  possibilities  have  been  excluded.  An  example 
will  illustrate  this. 

A  boy  aged  lo,  suffering  from  articular  effusion  of  both  knees, 
was  sent  into  the  hospital  as  a  suspected  case  of  tubercle.  But  as  the 
affection  was  on  both  sides,  and  as  there  were  no  other  indications,  we 
thought  the  case  was  one  of  chronic  rheumatism.  One  morning, 
however,  we  noticed  some  injection  of  the  eye  and  slight  cloudiness 
of  the  cornea,  which  had  supervened  since  the  previous  evening. 
This  at  once  suggested  "the  sins  of  the  fathers,"  and  it  was  clear  that 
the  serous  inflammation  of  the  knees  was  due  to  congenital  syphilis. 
The  result  of  mercurial  treatment  confirmed  this  diagnosis. 

If  there  has  been  no  attack  of  recent  parenchymatous  keratitis, 
hereditary  syphilis  may  probably  be  indicated  by  old  corneal 
opacities  or  by  the  shape  of  the  teeth,  in  addition  to  the  bilateral 
effusion.  In  other  cases,  we  may  ascertain  that  the  patient  bleeds 
easily,  and  that  any  pressure  leaves  a  blue  mark.  This  suggests  that 
an  early  stage  of  so-called  hsemorrhagic  effusion  is  present — but  this 
is  a  rare  contingency. 

We  have  hitherto  been  assuming  that  all  the  articular  diseases  are 
of  a  serous  nature.  Although  this  is  true  for  cases  of  congenital 
svphilis,  it  is  not  true  for  hjemorrhagic  joints  and  for  genuine  chronic 
rheumatism,  in  both  of  which  there  may  be  effusion  on  one  side  and 
ankvlosis  on  the  other. 

{b)  The  problem  is  quite  different  if  only  one  joint  is  aff'ected.  The 
most  important  question  is  whether  fnbercle  is  present.  In  addition, 
one  has  to  think  of  (i)  chronic  or  recurrent  traumatic  effusions, 
(2)  foreign  bodies  and  dislocation  of  a  semilunar  cartilage,  (3) 
gonorrhoea  with  an  unusually  protracted  course,  (4)  the  proximity  of 
a  focus  of  osteomyelitis,  (5)  tertiary  syphilis,  (6)  rheumatism  exception- 
ally remaining  in  one  joint,  (7)  a  neuropathic  joint,  and  finally,  (8) 
a  mono-articular  hsemorrhagic  effusion.  On  the  other  hand,  if  the 
effusion  is  limited  to  one  side,  hereditary  syphilis  may  be  confidently 
excluded.  We  will  deal  bi'iefly  with  these  possibilities,  reserving 
tubercle  till  the  end. 


CHRONIC    DISEASES    OF   THE    KNEE  68l 

Traumatic  effusions  come  on  in  an  acute  manner.  If  the  trauma 
is  frequently  repeated,  or  if  the  patient  is  rheumatic,  the  effusion  may 
become  chronic.  There  is  no  ev^ident  thickening  of  the  capsule,  and 
this  constitutes  the  distinction  from  tubercle  supervening  after  an 
injury.  The  "locking"  of  foreign  bodies  and  of  the  semilunar  carti- 
lages, are  distinguished  by  their  intermittent  character. 

A  knee,  the  mechanics  of  which  has  been  disturbed  by  a  fracture — 
even  extra-articular — may  be  subject  to  intermittent  and  remittent 
serous  effusions,  years  after  the  accident. 

The  diagnosis  of  chronic  gonorrhceal  effusion  is  made  from  the 
history  and  usually  also  from  the  condition  of  the  urethra. 

Synovitis  due  to  osteomyelitis  is  easy  to  recognize  if  the  patient 
has  the  scars  of  that  disease  on  the  femur  or  on  the  tibia.  There  are, 
howevei",  cases,  which  for  years  are  called  "rheumatism,"  when  in 
reality  an  abscess  exists  in  the  bone,  close  to  the  epiphysis,  and  some- 
what acute  attacks  occur  from  time  to  time,  accompanied  by  effusion 
into  the  joint.  We  must  depend  upon  the  history  for  the  correct 
diagnosis,  but  examination  will  show  that  the  main  situation  of  the 
swelling  and  of  the  pain  is  not  in  the  joint,  but  in  the  adjacent  bone. 

The  diagnosis  of  tertiary  syphilitic  synovitis  is  suggested  by  the 
history  and  the  slightness  of  the  pain  ;  but  one  cannot  be  certain  of 
its  accuracy  until  specific  treatment  has  met  with  success:  '  We  may 
assume  the  presence  of  chronic  mono-articular  rheumatic  synovitis 
if  the  capsule  is  not  markedly  thickened,  the  temperature  over  the 
joint  is  not  definitely  raised,  and  if  the  trouble  has  persisted  for  years 
without  getting  much  worse. 

Mild  forms  of  tubercle  may  drag  on  from  infancy  far  into  adult 
age  without  abscess  formation  and  with  a  tolerable  amount  of  move- 
ment, but  with  intermittent  exacerbations.  In  these  cases,  however, 
the  capsule  is  always  definitely  thickened. 

In  the  neuropathic  forms  the  diagnosis  is  established  by  the 
absence  of  pain,  despite  advanced  changes  in  the  joint,  and  by  the 
early  onset  of  deformity,  in  addition  to  the  pure  synovitis. 

This  variety  of  arthritis  has  been  appropriately  termed  a  "  carica- 
ture of  ordinary  arthritis."  If  symptoms  of  tabes  or  syringomyelia 
co-exist,  the  diagnosis  is  naturally  easier  ;  but  sometimes  it  will  be 
necessary  to  search  for  these  diseases,  because  the  joint  trouble  may 
be  the  first  symptom  of  nervous  disease  to  attract  the  attention  of  the 
patient. 

Haemorrhagic  effusion  has  already  been  referred  to.  We  have 
now  arrived,  by  way  of  exclusion,  to  tubercle,  which  is  by  far  the 
most  common  form  of  serous  inflammation  of  the  knee.  The  vast 
majority  of  these  cases  occur  in  infancy,  but  adults  may  become 
affected,  and  it  is  not  rare  even  in  old  age.  It  is  only  distinguished 
from  other  forms  of  serous  inflammation  by  the  fact  that  the  capsule 


SURGICAL   DISEASES   OF  THE    EXTREMITIES 


is  somewhat  thickened  from  the  very  beginning,  and 
elevation  of  the  temperature  over  the  diseased  joint, 
of  the  capsule  must  always  be  looked  for  at  its /o/c/s, 
its  superior  border,  and  on  both  femoral  condyles, 
knee  is  examined  at  the  same  time  it  will  be  easy  to 
far  the  folds  can  be  palpated  in  the  normal  condition. 

If  the  joint  is  full  and 
tense,  this  sign  cannot  be  de- 
monstrated. In  such  a  case,  the 
joint  should  be  puncUired,  and 
a  positive  diagnosis  will  be 
obtained  by  examining  the 
fluid.  Blood,  pure  or  nearly 
so,  indicates  haemorrhage  into 
tlie  joint.  Clear,  serous,  or 
mucous  fluid  may  be  found  in 


by  the  persistent 
The  thickening 

that  is  to  say,  at 

If  the  healthy 

appreciate  how 


Fig.  426. — Slight  tubercular  hydroi.'^  of 
the  right  knee  with  almost  completely  free 
mobility.  Very  slight  muscular  atrophy,  con- 
sidering that  the  disease  has  lasted  nine  years. 


Fig.  427.  —  Proliferating  tubercular  disease  of 
knee,  wiih  moderate  amount  of  serous  effusion. 
Mobility  still  partially  retained. 


every  variety  of  inflamed  knee,  but    if   the  fluid  is  purulent,  turbid, 
or  contains  shreds  of  fibrin,  the  case  is  probably  tubercular. 

In  order  to  test  the  temperature,  it  suffices  to  lay  both  hands  lightly 
upon  the  two  equally  long  exposed  knees.  Effusions  due  to  gonor- 
rhoea, osteomyelitis  and  recent  injury,  show  some  local  elevation  of 
temperature,  but  this  vanishes  much  more  rapidly  than  in  tubercle, 
wherein  the  same  amount  of  heat  can  be  detected  for  many  months 
at  each  examination. 


CHRONIC   DISEASES   OF   THE    KNEE 


683 


Fig.  428(2. — Normal  knee. 


We  might  expect  tliat  tubercular  disease  of  the  knee-joint  would 
lead  to  earlv  liinifafioii  of  movements,  as  occurs  with  other  joints. 
But,  as  a  matter  of  fact,  this  is  very  often  not  the  case.  The  excur- 
sions of  the  knee  may  remain  perfectly  free  even  in  tubercular 
synovitis  of  many 
years'  standing,  as  long 
as  the  joint  is  not  over 
distended  by  the  efifu- 
sion.  In  such  cases 
the  muscular  atrophy 
does  not  supervene  as 
soon  as  it  does  in  tu- 
bercle with  early  anky- 
losis. 

IfV  iiuiv  bi'ic/lv  sii Hi- 
ll uirizc  ilie  above,  as 
folloics  :  Every  iiwiio- 
artieiilar,  eliroiiie,  se- 
rous in/iaiiniiafion  of 
flie  knee,  icJierein  there  is 
definite  tJiickening  oftJie 
reftected  fotds  of  ttie  cap- 
sule, and  wJiereiu  there 
is  a  persistent  definite 
local  elevation  of  tem- 
perature, must  be  re- 
garded as  tubercular, 
even  if  mobility  still 
remains  free  and  pro- 
nounced nrusadar  atro- 
phy is  absent.  Notliing 
but  very  clear  evidence 
to  the  contrary  ivar- 
rants  us  in  departing 
from  this  rule  of  dia- 
gnosis. 

In  rare  cases,  one  or 
more  movable  foreign 

bodies  may  be  felt  in  the  swollen  joint.  They  are  not  completely 
free  and  can  only  be  moved  in  a  small  circle.  These  are  examples 
of  the  polypoid  form  of  tubercular  knee  (Plate  lY,  fig.  b).  The 
polypi  consist  of  hard  connective  tissue,  more  or  less  abundantly 
permeated  by  tubercles. 


Fig.  428^.     Tubercular   knee.      Secondary   erosion  of  bone 
at  X  X.     Cartilage  somewhat  narrowed. 


44 


684 


SURGICAL   DISEASES    OF   THE    EXTREMITIES 


(2)  FUNGATING   INFLAMMATION  OF  THE   KNEE-JOINT. 

If  the  capsule  is  greatly  thickened  in  a  dijfuse  manner,  the  case 
is  either  tubercle,  or  tlie  very  rare  condition  of  gummatous  arthritis, 
whether  there  be  effusion  present  or  not. 

Localized  fungating  degeneration  of  the  capsule  might,  apart  from 
gumma,  be  confused  with  the  rare  condition  of  sarcoma  of  the 
articular  capsule,  if  the  joint  is  movable.  But  as  we  have  already 
seen,  free  mobility  does  not  by  any  means  exclude  tubercle.  In  other 
cases,  however,  movement  is  soon  interfered  with,  and  finally  com- 
plete rigidity  supervenes. 


Fig.  429. — Tubercular  knee,  with  complete  des- 
truction of  articular  surfaces,  and  with  an  area  of 
disease  in  the  internal  condyle  of  the  femur. 


Fig.  430. — Tubercular  knee  with  area  of  disease, 
and  a  sequestrum  in  the  patella  (x). 


A  momentary  glance  often  suffices  to  distinguish  these  two  forms, 
before  we  ask  the  patient  to  make  any  movements.  If  the  mobility  is 
preserved  the  muscles  of  the  thigh  and  leg  are  not  strikingly  atrophied, 
and  the  thickened  capsule  resembles  a  moderate  amount  of  effusion, 
more  especially  as  some  effusion  usually  exists.  In  cases  of  early 
rigidity,  however,  the  diffusely  swollen  knee  is  slightly  bent,  the 
muscles  of  the  thigh  and  knee  are  wasted,  so  that  a  spindle-shaped 
appearance  results. 

The  principal  question  from  the  diagnostic  standpoint  is  whether 


Plate  4. 


Diagrammatic  Representation  of  various  forms  of  Tubercular  disease  of  the  Knee. 


Light  pink     =  normal  bone 

Blue  =  cartilage 

Red  =  Inliamed  Synovial  membrane 

Ulght  yellow  =  serous  effusion 

Green  =  pus 

Orange  ^=  Caseous  thickening 


a.  Serous  inflammation  of  Knee.  Synovial  membrane  slightly  thick- 
ened, invaded  by  tubercles.     Serous  effusion. 

b.  Polypoid  Inflammation  of  Knee.  On  synovial  membrane  large 
fibrous  polypi  wHh  tubercles. 

c.  Fungating  inflammation  of  Knee.  Slight  exudation.  Much 
thickening  of  synovial  membrane. 

d.  Pungating  &  caseating  inflammation  of  Knee.  Caseous  thickening 
of  fungating  masses.  Purulent  exudation.  Abscess  behind  bend 
of  Knee. 

e.  The  same,  but  cartilage  of  bone  removed  and  destroyed  by 
tubercular  proliferation. 

/.  Primary  disease  of  bone,  in  the  form  of  a  wedge  shaped  area, 
with  sequestrum. 


Quervain,  IHagnostic  Surgery. 


CHRONIC    DISEASES    OF    THE    KXEE 


685 


the  condition  is  of  :i  purely  fiiiigafiiig  character,  with  or  without  serous 
effusion,  or  whether  it  has  become  pitnilciif.  We  may  confidently 
assume  that  suppuration  has  occurred  if  there  appear  a  circumscribed, 
elastic,  or  fluctuating  bulging,  which  seems  to  be  just  under  the  skin. 
This  appearance  may 
present  anywhere,  but  it 
is  most  frequent  at  the 
level  of  the  joint  cleft. 

It  used  to  be  the 
practice  to  incise  such 
swellings  early,  in 
order  to  see  their  con- 
tents, or  to  remain  loyal 
to  the  old  maxim  "  iibi 
pus,  ibi  cvacua."  As 
a  rule  the  abscess  re- 
fused to  heal  ;  a  fistula 
developed  and  secon- 
dary infection  occurred. 
In  this  condition  the 
case  was  turned  over 
to  the  surgeon.  We 
now  know  that  such  an 
incision  into  a  tuber- 
cular abscess  of  a  bone 
or  a  joint,  however 
aseptically  performed, 
almost  unavoidably 
leads  to  secondary  in- 
fection by  pus  organ- 
isms and  does  the 
patient  considerable 
harm.  It  is  only  justi- 
fiable to  open  a  tuber- 
cular abscess  if  one  is 
prepared  to  proceed 
forthwith  to  a  radical 
removal  of  the  dis- 
eased area  in  the  bone 
or  of  the  capsule. 

Even  if  the  tuber- 
cular nature  of  the 
malady  is  doubtful,  in- 
cision is  unjustifiable. 
An    aseptic   exploratory 

puncture  suffices  to  obtain  the  requisite  information,  and  does  no 
liarm  to  the  patient.  If  staphylococci  or  streptococci  can  be  culti- 
vated from  the  unincised  joint,  the  disease  is  osteomyelitis — or,  more 
rarely,  an  acute  suppurating  arthritis.     If  the  cultures  remain  sterile, 


Fig.  431. — Tubercular  knee,  slightly  flexed  and  con- 
tracted, and  in  valgus  position,  with  subluxation  of  the 
tibia  backwards  and  outwards. 


686  SURGICAL    DISEASES    OF   THE    EXTREMITIES 

and  gonorrhoea  can  be  excluded,  the  case  is  certainly  tuberculosis.  A 
decisive  conclusion  would  be  given  by  animal  inoculation. 

We  have  already  made  several  references  to  the  starting-points  of 
disease.  The  bone  lesion  is  very  often  secondary,  as  shown  by  the 
existence  of  numerous  smaller  foci  on  the  articular  surface  of  the  bone, 
especially  where  the  capsule  is  reflected  (fig.  428).  We  should  only 
assume  that  the  disease  in  the  bone  is  primary,  if  an  extra-articular 
lesion  is  clinically  demonstrable  in  a  case  wherein  the  joint  is  but 
slightly  aifected,  or  if  the  skiagram  reveals  a  large  localized  lesion. 
Such  lesions  may  be  in  the  femur  (fig.  429)  or  in  the  tibia,  and  excep- 
tionally in  the  patella  (fig.  430).  The  latter  is  indicated  by  striking 
tenderness  on  pressure  over  the  knee-cap. 

There  are  some  rare  cases,  in  which  examination  leaves  one  in  doubt 
as  between  a  serous  effusion  and  a  fungating  thickening  of  the  capsule, 
and  on  operation  it  is  found  that  neither  one  nor  the  other  exists,  but 
that  the  condition  is  one  of  a  lipoma-like  proliferation  of  the  articular 
tufts — so-called  lipoma  arborescens.  As  this  change  may  occur  in 
chronic  arthritis  of  different  origins,  and  exceptionally  also  in  tubercle, 
it  is  not  easy  to  make  an  accurate  diagnosis.  I  have  found  this  con- 
dition limited  to  the  upper  segment  of  the  joint. 

(3j   RIGIDITY. 

If  contractures  are  present,  the  conditions  which  come  into 
consideration  for  diagnosis  are  again  abundant.  One  must  first  put 
aside  those  cases  wherein  the  history  points  to  some  form  of  acute 
infective  inflammation  of  the  knee-joint,  preceding  the  contracture  or 
ankylosis.  We  have  only  to  consider  rigidity  of  gradual  onset,  and  may 
even  then  be  in  doubt  as  to  the  (i)  terminal  stage  of  haemorrhage  into- 
the  joint,  which  is  rare  ;  (2)  chronic  articular  rheumatism^  forming 
adhesions  ;  and  (3)  tubercle  causing  early  rigiditv. 

The  previous  history  will  indicate  whether  there  has  been 
haemorrhage  into  the  joint. 

Articular  rheumatism,  producing  ankylosis,  is  as  rarely  mono- 
articular as  tubercle,  producing  ankylosis,  is  polyarticular.  Further,, 
the  ankylosing  form  of  tubercle  is  always  associated  with  some  thicken- 
ing of  the  capsule,  and  with  local  elevation  of  temperature  and 
often  with  fistulas,  unless  the  process  is  completely  at  an  end.  Cases 
of  tubercular  polyarthritis,  wherein  the  diagnosis  remains  uncertain 
for  many  years,  exist,  but  they  are  very  rare. 

The  contracture  does  not  alwa^'s  develop  into  a  simple  flexion.  We 
often  find,  especially  in  tubercle,  that  the  posture  is  one  of  slight  valgus, 
with  subluxation  of  the  tibia  backwards  and  outwards,  as  illustrated 
in  fig.  431. 


TUMOURS    AXD    ALLIED    STRUCTURES    ABOUT   THE    KX'EE-JOIXT      68/ 


CHAPTER  C. 

TUMOURS  AND  ALLIED  STRUCTURES  ABOUT  THE 

KNEE-JOINT. 

The  knee-joint  occasionally  presents  structures  which  do  not  fit  in 
^vith  the  previously  described  bone  sarcomata,  arising"  from  the  femur 
or  tibia,  nor  with  chronic  inflammatory  processes, 

(a)   Let  us  begin  with  the  aitferior  surface. 

Chronic  prepatellar  bursitis  is  at  once  evident,  even  to  the 
beginner,  owing  to  its  superficial  position,  in  front  of  the  patella.  The 
structure  may  vary  in  size  from  an  almond  to  a  fist,  and  accurate 
anatomical  examination  shows  that  it  may  be  just  under  the  skin, 
under  the  superficial  fascia,  or  under  the  deep  aponeurosis.  Diverti- 
-cula  extending  laterally  are  of  importance  from  the  operative  stand- 
point. 

If  the  wall  of  the  structure  is  strikingly  thick  and  persistently  painful 
on  pressure,  one  should  think  of  tubercle  of  the  bursa,  which  is,  how- 
ever, rare.  X-rays  will  show  whether  it  originates  in  tubercle  of  the 
knee-cap. 

Occasionally,  a  change,  corresponding  to  prepatellar  bursitis,  is 
found  somewhat  lower  down,  situated  in  front  of  the  patellar  ligament. 
{Bursitis  prcvtibialis).  Bursitis  of  the  deep  iufra-patcUar  bursa  bchiud 
the  patellar  ligament  is  still  more  rare.  The  swelling  has  a  sub-divided 
appearance,  and  bulges  on  both  sides  of  the  ligament.  The  larger  it  is, 
the  more  it  interferes  with  the  movements  of  the  joints. 

Among  the  rare  tumours  of  the  anterior  surface  of  the  joint 
should  be  noted,  sarcoma  of  the  patella;  lipoma,  fibroma 
and  sarcoma  of  the  synovial  membrane  or  the  sub-synovial 
connective  tissue.  Lipoma  arborescens,  i.e.,  lipomatous  proHfera- 
tion  of  the  articular  fringes,  has  already  been  mentioned  as  occur- 
ring in  various  forms  of  chronic  arthritis  and  in  tubercle.  It  may 
be  regarded  as  on  the  border  line  of  tumour  formation.  Fibrous 
polypi  which  may  attain  the  size  of  almonds  and  which  feel  very 
much  like  foreign  bodies  within  the  joint,  are  seen  in  rare  cases 
of  tubercle  (Plate  IV,  fig.  b).  The  freedom  of  the  joint  movements 
is  characteristic  of  all  these  tumours. 

(6)  With  few  exceptions,  swellings  in  the  popliteal  space  are 
either  extensive  bursae  or  aneurisms.  The  distinction  is  at  once 
<;vident  on  palpation  and  inspection,  from  the  absence  or  presence 
of  pulsation.  This,  however,  may  occasionally  be  absent,  even  in 
the  case  of  an  aneurism,  if  its  contents  are  coagulated.  But  no 
mistake    ought    to    arise,    as    the    consistence    of    the    structure    is 


688 


SURGICAL    DISEASES    OF   THE   EXTREMITIES 


comparatively  firm,  and  the  patient  can  always  testify  to  the  previous 
presence  of  pulsation.  Soft  or  elastic  non-pulsatile  swellings  are, 
as  a  rule,  enlarged  burs^e  ;  the  bursa  under  the  popliteus,  if  situated 
laterally,  and  the  seiiiiuiembranoiis  bursa,  if  situated  towards  the 
middle  line.     They  may  be  confused  with  the  very  rare  lipomata  of 

this  region,  and  also  with  a  cold 
abscess.  Differentiation  is  easy,  if 
the  contents  of  the  swelling  can  be 
reduced  into  the  knee-joint,  as  is 
often  possible  in  enlarged  bursae. 
Otherwise,  if  the  swelling  is  very  easily 
displaced,  we  should  regard  it  as  a 
lipoma ;  if  it  has  an  atypical  situa- 
tion, is  painful  on  pressure,  and  if  the 
movements  of  the  joint  are  also  in- 
terfered with,  we  should  regard  it  as  a 
cold  abscess.  If  the  abscess  origin- 
ates in  an  extra-articular  lesion,  it  may 
not  be  possible  to  diagnose  it  without 
a  skiagram  and  an  exploratory  punc- 
ture. 

Effusion  into  a  bursa  may  be  due 
to  chronic  serous  (rheumatic)  inflam- 
mation of  the  knee-joint.  The  removal 
of  the  bursa  is  then  occasionally  fol- 
lowed by  an  unusually  severe  effusion 
into  the  joint. 

We  need  only  add,  in  reference  to  the  unmistakable;  diagnosis  of 
aneurism,  that  this  soon  causes  neuralgic  pains  and  paraesthesia  in 
the  leg,  and  that  it  may,  after  reaching  a  certain  size,  fix  the  joint 
in  semi-flexion.  It  is  due  to  the  same  causes  as  other  aneurisms, 
i.e.,  trauma,  arteriosclerosis  and  syphilis — especially  the  last,  even  if 
there  is  a  history  of  injur}-. 


Fig.  432. — Prepatellar  bursitis. 


SCIATICA   AND   OTHER   PAINFUL   DISEASES   OF   THE    LOWER   LIMBS     689 


CHAPTER  CI. 

SCIATICA  AND  OTHER  PAINFUL  DISEASES  OF 
THE  LOWER  LIMBS. 

Medical  nosology  contains  a  number  of  vague  terms  whicli 
fortunately  help  to  conceal  the  bitter  truth  from  a  patient,  without 
prejudicing  the  diagnosis,  but  unfortunately  these  terms  occasion- 
ally satisfy  the  doctor  as  well  as  the  patient,  to  the  latter's  great 
detriment.  Thus  a  multitude  of  ills  mav  be  embraced  under  the 
designations  of  anaemia,  liver  trouble,  intestinal  colic,  &c.  The 
same  is  true  of  "  sciatica."  Neuralgic  pains  of  the  lower  extremity 
are  often  summarilv  diagnosed  as  sciatica,  as  if  this  condition 
were  a  clinical  entity. 

Although  references  have  already  been  made  to  this  subject, 
we  shall  once  more  describe  how  a  case  of  "sciatica"  should  be 
examined,  not  only  by  a  surgeon,  but  by  any  practitioner. 

It  is  most  important  to  examine  the  urine  and  the  reflexes — 
patellar  and  pupillary — because  the  condition  may  be  due  to  diabetes, 
tabes  or  paralysis.  Then  the  surgical  possibilities  must  be  thought 
of.  The  gluteal  region  must  be  palpated,  because  an  obstinate 
sciatica  may  be  the  first  symptom  of  sarcoma,  originating  in  the 
bone  or  muscle.  The  course  of  the  nerve  must  be  followed,  because 
sciatica  may  be  due  to  a  malignant  growth  of  the  thigh  or  even 
lower  down.  A  diffuse  thickening  of  the  shaft  of  the  femur, 
indicating  chronic  osteomyelitis,  may  possibly  be  found.  If  an 
injury  has  preceded  the  sciatica  the  question  of  a  foreign  body 
may  arise. 

A  3^oung  man  fell  on  a  heap  of  wooden  palings,  while  in  an 
inebriated  state.  He  was  subsequently  treated  for  many  weeks  for 
"  sciatica,"  and  a  colleague  of  mme  then  succeeded  in  withdrawing 
a  long  piece  of  paling.  The  original  wound  had  healed  com- 
pletely over  the  piece  of  wood. 

If  palpation  elicits  nothing,  we  must  direc  our  examination 
towards  the  spine.  Spinal  caries,  sarcoma  of  the  lumbar  vertebrae, 
or  caries  of  the  ileo-sacral  joint  may  simulate  a  simple  sciatica. 

If  the  patient  is  a  young  man,  of  an  age  when  idiopathic  sciatica 
is  rare,  we  should  inquire  about  gonorrhcea,  and,  if  necessary, 
examine  the  urethra. 

I  was  once  consulted  by  a  young  man  for  sciatica.  My  inquiry 
regarding  gonorrhoea  was  answered  by  a  decided  and  resentful 
negative  in  the  presence  of  his  father.  But  the  youth  reappeared 
on  the  following  day,  saying  :  "  I  have  merely  come  to  tell  you 
that  you  were  quite  right." 


690  SURGICAL   DISEASES   OF   THE   EXTREMITIES 

This  cause  should  also  be  borne  in  mind,  even  in  the  case  of 
patients  of  advanced  age. 

A  grey-haired  grandmother  consulted  me  for  sciatica.  She  was 
also  suffering  from  a  profuse  white  discharge.  Had  her  husband 
not  consulted  me  a  fortnight  previously  for  gonorrhcea,  I  would 
hardly  have  diagnosed  the  cause  of  her  sciatica  correctly. 

We  now  proceed  to  rectal  examination.  This  should  never  be 
neglected  in  a  case  of  sciatica,  however  objectionable  it  may  be 
to  the  patient  and  unpleasant  for  the  practitioner.  We  examine 
in  both  sexes  for  cancer  of  the  rectum  and  for  new  growth  in 
the  pelvis  ;  for  malignant  disease  of  the  prostate  in  males  and  for 
some  disease  of  the  generative  organs  in  the  female.  In  the  latter 
a  vaginal  examination  should  also  be  made.  If  this  systematic 
examination  were  invariably  practised,  we  should  no  longer  come 
across  cases  wherein  women,  at  the  climacteric  age,  have  been 
treated  for  weeks  or  months  for  sciatica,  until  at  length,  an  offensive 
discharge  or  profuse  haemorrhage  has  led  to  a  gynjecological 
examination.  The  doctor  is  not  always  to  blame.  Female  patients 
often  refuse  a  vaginal  or  rectal  examination  because  they  cannot 
conceive  what  bearing  it  has  on  their  sciatica.  The  young,  inexperi- 
enced practitioner  may  yield  to  this  refusal,  but  nevertheless  he 
incurs  the  responsibility  for  his  error  of  diagnosis.  It  may  be  said 
that  such  an  error  is  of  no  consequence  to  the  patient,  because 
a  malignant  tumour,  which  has  caused  sciatica,  is  already  beyond 
radical  removal.  Although  this  may  be  correct  in  the  majority  of 
instances,  it  is  nevertheless  true  that  an  accurate  diagnosis  is 
better,  not  only  for  the  reputation  of  the  practitioner,  but  also  for 
the  interests  of  the  patient  and  his  friends,  than  futile  spa  and 
electric  treatment  and  similar  measures.  But  not  all  gynaecological 
diseases  which  cause  sciatica  are  of  malignant  nature.  Pelvic 
exudations  and  incarcerated  myomata  may  irritate  the  sciatic  nerve ; 
indeed  rectal  constipation  may  sometimes  explain  sciatic  pains. 

Is  it  possible  to  distinguish  clinically  the  sciatica  which  results 
from  malignant  growths  from  idiopathic  sciatica  ?  The  pain  in 
the  former  is,  on  the  whole,  persistent,  in  the  latter  it  is  rather  of 
a  paroxysmal  nature.  In  sciatica  due  to  cancer  the  patients  soon 
exhibit  a  peculiar  restlessness.  Even  if  the  pain  is  not  severe  they 
are  still  restless,  whatever  posture  they  adopt.  They  cannot  be 
persuaded  to  sit  down,  even  in  the  doctor's  consulting  room;  they 
often  persist  in  walking  up  and  down  restlessly.  In  simple  sciatica 
the  disturbances  aie  limited  to  sensations  of  pain,  there  is  not 
usually  any  loss  of  sensibility.  If,  however,  it  should  be  present, 
it  does  not  usually  reach  any  extreme  degree.  There  are  never 
any  disturbances  of  motion.  But  both  these  conditions  are  as  a 
rule  present  in  advanced  cases  of  sciatica,  due  to  compression. 
Carcinoma    may  also    produce  nerve    manifestations,  owing   to    the 


SCIATICA    AND    OTHER    PAIXP^UL    DISEASES    OF   THE    LOWER    LIMBS     69I 

wandering  and  proliferation  of  cancer  cells  into  the  lymphatics  of 
the  nerve  trunk.  We  must  therefore  regard  "  sciatica,"  which  comes 
on  after  removal  of  rectal  or  uterine  cancer,  as  a  recurrence, 
although  we  may  not  be  able  to  detect  any  cancerous  mass  com- 
pressing the  nerve. 

If  old  people  complain  of  severe  "sciatica  pains"  in  the  leg 
extending  to  the  toes — pains  which  often  come  on  quite  suddenly 
and  cause  limping,  we  should  think  of  Charcot's  ''intermittent  limp," 
and  should  at  once  inquire  whether  attacks  of  pallor  or  bluish-red 
discoloration  occur  in  tlie  painful  extremity.  The  occurrence  of  such 
attacks  indicates  the  prospect  of  gangrene,  especially  if  on  exami- 
nation the  foot  is  sometimes  found  to  be  pale  and  cold  and  at 
other  times  in  a  state  of  venous  congestion.  This  diagnosis  would 
be  confirmed  by  the  obliteration  of  the  pulse  in  the  dorsalis  pedis 
artery  and  posterior  tibial,  and  certainly  by  the  absence  of  the 
popliteal  pulse.  This  cause  for  pain  is  especially  prevalent  among 
old  people,  as  the  expression  "senile  gangrene"  indicates.  Younger 
people  are,  however,  not  immune  from  gangrene,  but  in  their  case 
some  special  cause  is  responsible,  e.g.,  diabetes,  early  syphilitic 
arteriosclerosis,  or  acute  infectious  disease,  typhoid  fever  being  the 
most  common.  I  have  seen  thrombosis  of  both  femoral  arteries  and 
eventually  of  the  abdominal  aorta,  follow  a  slightly  septic  finger  in 
a  girl  aged  20.  In  some  cases,  however,  no  antecedent  disease  can 
be  discovered.  These  cases  are  included  under  the  comprehensive 
term  of  Raynaud's  disease,  the  principal  indication  of  which  is  its 
symmetry.  This  condition  is  attributed  to  a  primary  vasomotor 
disturbance,  for  want  of  a  l^etter  explanation. 

The  following  case  belongs  to  this  category,  although  the  affection 
is  unilateral  : — 

A  healthy  man,  aged  30,  who  had  not  suffered  from  syphilis, 
began  to  complain  of  severe  neuralgia  of  his  left  foot.  There  was 
no  obvious  cause  for  this,  except  perhaps  excessive  gymnastics.  The 
foot  was  sometimes  pale  and  cold,  at  others,  bluish-red.  Eventually 
the  cyanotic  discoloration  persisted  and  gangrene  of  the  foot 
developed,  requiring  amputation.  Pains  and  vasomotor  disturbances 
supervened  a  few  years  later  in  the  other  foot,  but  gangrene  did  not 
follow. 

We  should  think  of  arteriosclerosis,  in  the  absence  of  any  other 
cause,  if  pain  is  present,  even  without  severe  vasomotor  disturbances. 

Varicose  veins  should  also  be  included  among  the  causes  of  pain 
and  "cramp"  in  the  leg,  especially  in  the  calf.  Deep  varicose  veins 
are  conveniently  blamed,  when  the  diagnosis  is  obscure,  because  the}^ 
cannot  be  seen,  and  therefoi'e  their  presence  cannot  be  denied. 

On  the  other  hand,  sciatica  may  be  mistaken  for  some  other 
condition — especially  the  form  of  sciatica  termed  scoliosis  iscliiadica 
(Chapter  LXXIX).    Patients  with  sciatica  often  walk  with  an  oblique 


692  SURGICAL   DISEASES   OF^   THE   EXTREMITIES 

gait,  inclining  the  trunk,  sometimes  to  the  healthy  side,  at  others  to  the 
affected  side.  A  beginner,  unaware  of  this  habit,  may  easily  devote 
his  chief  attention  to  the  scoliosis,  and  look  upon  the  sciatica  as  a 
secondary  matter.  This  view  would,  however,  only  be  justified  in 
those  rare  cases  wherein  the  sciatica  results  from  disease  of  the  lumbar 
spine,  such  as  caries,  and  the  scoliosis  is  a  consequence  of  the 
lateral  compression  of  the  diseased  vertebra.  In  such  cases,  all  doubt 
is  removed  by  the  tenderness  of  the  affected  spinous  process  and 
the  pain  elicited  by  axial  pressure.  But  in  cases  of  true  "  scoliosis 
ischiadica  "  the  condition  is  one  of  primary  disease  of  the  nerve.  The 
patient  endeavours  to  relax  the  sciatic  nerve  by  abducting  and  slightly 
flexing  his  leg.  Ehret  has  shown  that  this  posture  causes  a  remark- 
able approximation  of  the  terminal  points  of  the  trunk  of  the  sciatic 
nerve.  The  patient  involuntarily  compensates  for  the  pelvic  inclina- 
tion thus  caused  by  assuming  the  posture  of  scoliosis  and  slight 
lumbar  lordosis. 

Recent  researches,  however,  appear  to  show  that  scoliosis  is  more 
frequently  due  to  involvement  of  the  lumbar  nerves  in  the  morbid 
process. 

The  foregoing  remarks  regarding  sciatica  apply  iiiiitntis  uiittandis 
to  neuralgia  affecting  the  anterior  crural  nerve,  the  external 
cutaneous  and  the  obturator  nerves.  But  as  neuralgia  of  these 
nerves  rarely  occurs  as  an  idiopathic  affection,  it  is  more  likely  than 
sciatic  neuralgia  to  suggest,  even  to  the  beginner,  some  special  cause. 
Search  should  be  made  for  pelvic  tumours,  spinal  caries,  burrowing 
abscesses,  and  also  for  malignant  retroperitoneal  and  inguinal  glands. 
The  primary  growth  may  be  situated  in  any  part  of  the  area  drained 
by  these  glands,  so  that  the  whole  of  it  will  require  investigation. 

Obturator  hernia  may  be  the  cause  of  an  obturator  neuralgia,  but 
as  advice  is  not  usually  sought  for  this  hernia  until  strangulation  takes 
place,  it  IS  necessary  to  inquire  for  this  neuralgia,  in  order  to  ascertain 
anything  about  it.  If  it  is  present,  it  enables  us  to  exclude  internal 
intestinal  obstruction. 

Neuralgia  of  the  external  femoral  cutaneous  nerve  has  been 
described  as  a  disease,  sui  generis,  and  provided  with  the  designation  of 
"meralgia  paraesthetica."  This  term  should,  however,  not  induce  us 
to  abandon  attempts  to  form  a  more  accurate  diagnosis.  As  the 
position  of  this  nerve  exposes  it  to  external  damage,  we  should  always 
think  of  some  isolated  or  repeated  injurv  {e.g.  the  friction  of  an 
abdominal  belt)  if  there  be  no  other  cause  of  neuritis.  It  may  be 
mentioned  incidentally  that  this  meralgia  has  been  described  as  a 
consequence — very  indirect — even  of  ffat  foot. 

Many  painful  conditions  of  the  foot  have  received  special  names^ 
e.g.,  talalgia,  tarsalgia,  Morton's  nietatarsalgia,  ptenialgia,  &c.  The 
practitioner  is  apt  to  believe  that  a  diagnosis  has  thus  been  made,  and 
that  there  is  no  further  need  to  search  for  the  cause  of  the  pain.  This 
cause  may,  however,  reside  in  the  most  varied  conditions  of  disease. 
Flat  foot  is  the  most  frequent  of  these,  but  they  include  the  sequelae  of 


ULCERS    OF   THE    LEG  693 

injury,  localized  inflammatory  changes  in  the  burs^e,  tendon  sheaths, 
joints,  ligaments,  fascias,  and  also  gout,  neuritis  (alcohol),  and  tabes, 
apart  from  various  neurasthenic  pains  and  the  result  of  badly-fitting 
boots. 

Finall}^,  it  must  not  be  forgotten  that  women  often  complain  of 
severe  pains  and  para^sthesia  in  the  legs  at  the  menopause.  The 
correct  diagnosis  is  frequently  suggested  by  the  fact  that  similar 
sensations,  although  of  a  less  severe  character,  are  experienced  in 
the  arms. 


CHAPTER    CII. 
ULCERS   OF   THE    LEG. 

"  Ulcer  of  the  leg  "  has  become  quite  a  standard  type  of  lesion, 
so  that  the  beginner  is  apt  to  imagine  that  there  is  only  one  variety  of 
ulcer  in  this  region.  In  addition  to  the  ulcerative  processes  which 
occur  around  the  orifices  of  fistulie,  and  which  ma}^  themselves  be  of 
a  tubercular  nature  if  the  fistulze  are  tubercular,  there  are  three  other 
forms  of  ulcer  which  affect  the  leg,  Lc,  (i)  varicose  ulcer.  (2)  syphilitic 
nicer,  and  (3)  cancer  of  the  skin. 

Varicose  ulcers  are  usually  already  diagnosed  bv  the  patient. 
As  they  preponderate  enormously  over  the  other  two  forms,  we  are 
justified  in  accepting  the  patient's  diagnosis  in  most  cases — not 
however,  before  seeing  the  ulcer.  Varicose  ulcers  vary  so  much 
according  to  the  stage  in  which  we  see  them  that  we  cannot  speak 
of  any  characteristic  appearance.  Sometimes  we  see  a  brownish-red, 
hard  infiltration  of  the  skin  with  a  circumscribed,  superficial,  and 
remarkably  painful  erosion  in  its  centre.  The  beginner  looks  upon 
this  as  too  trifling  to  deserve  the  name  of  ulcer,  until  he  learns  by 
experience  that  this  erosion,  unless  it  is  treated,  may  develop  into  an 
ulcer  lasting  for  weeks  and  even  for  months.  Sometimes  this  will 
occur,  even  if  the  erosion  does  receive  treatment. 

An  ulcer  of  the  leg  may  present  itself  as  a  deeplv  penetrating  loss 
of  substance  from  the  skin,  with  a  necrotic  base,  and  with  edges 
which  are  serpiginous,  steeply  shelving,  or  even  undermined.  This 
may  be  a  simple  ulcer  of  the  leg  without  any  other  supplementary 
element.  The  ofl'ensive  discharge  and  the  inflamed  area  around 
merely  indicate  neglect,  either  due  to  social  causes  or  to  laziness.  At 
other  tin.ies  we  find  a  flat  ulcer  with  a  granulating  base  and  smooth 
edges,  on  which  new  epithelium  is  developing.     Obviously  this  must 


^94 


SL'KGICAL    DISEASES    OF    THE    EXTREMITIES 


be  an  ulcer  on  the  point  of  healing,  and  the  duty  both  of  the  patient 
and  practitioner  is  to  do  nothing  to  interfere  with  the  heahng  process, 
by  unsuitable  treatment  or  inappropriate  conditions. 

Are  varicose  veins  really  indispensable  for  the  diagnosis  of  a 
varicose  ulcer  ?  As  a  rule  they  are  present  ;  but  sometimes  it  is 
necessary  to  search  for  them,  and  for  this  purpose  the  patient  must 
stand  up  for  a  little  while.  If  the  patient  has  been  confined  to  bed 
for  any  length  of  time,  it  may  be  impossible  to  see  even  very  pro- 
nounced   varicose   veins.      The   absence    of   any    abnormally  dilated 

veins,  does  not,  however,  justify  us  in 
assuming  a  syphilitic  basis  for  the  ulcer. 
It  is  more  likely  to  have  resulted  from 
some  indefinite  injury,  from  an  abra- 
sion or  contusion  of  the  skin,  which  has 
developed  into  an  ulcer  owing  to  the 
unfavourable  healing  conditions  of  the 
leg,  or  through  neglect.  These  ulcers 
heal  rapidlv  if  the  patient  lies  in  bed,  and 
if  the  necessarv  cleanliness  is  adopted 
in  the  treatment  of  the  wound.  On  the 
other  hand,  the  presence  of  varicose  veins 
is  not  in  itself  enough  to  justify  the 
diagnosis  of  a  varicose  ulcer.  Syphilitic 
patients  may  have  varicose  veins  which 
probably  encourage  the  development  of 
gummatous  processes. 

The  appearance  of  the  ulcer,  as  already 
indicated,  shows  us  the  stage  of  the  ulcer, 
but  does  not  of  itself  tell  us  anything 
definitely  of  its  origin.  Many  errors  will 
be  made  if  all  ulcers  which  are  some- 
what polycircular  in  shape  or  have  ser- 
piginous edges  are  put  down  to  syphilis, 
or  if  all  undermined  ulcers  are  regarded 
as  cancerous.  There  can,  of  course,  be  no  doubt  about  syphilis,  if  the 
polycircular  shape  is  very  pronounced,  probably  in  several  ulcers,  if 
there  also  co-exist  round,  kidney-shaped  or  horse-shoe-shaped  erosions 
of  the  skin,  looking  as  if  they  had  been  punched  out  with  a  perforating 
apparatus,  and  if  they  have  been  preceded  by  well-defined,  painless, 
cutaneous  gummata,  instead  of  a  diffuse,  hard  and  painful  infiltration 
of  the  skin.  The  localization  of  these  morbid  changes  is  very  striking 
in  less  typical  cases.  Simple  ulcers  of  the  leg  are  situated  in  its  lower 
half,  extending  as  far  as  the  malleoli.  They  may  affect  any  part  of  this 
region,  the  front,  back,  the  external  or  internal  surface,  and  may  even 


Fig.  433. — Varicose  ulcers  of  ihe  leg. 


ULCERS    OF   THE    LEG 


69: 


become  rini^'-shaped.  Ulcers  situated  higher  up  towards  the  knee,  or 
lower  down  on  the  dorsum  of  the  foot,  may  indeed  be  due  to  injury 
or  to  a  ruptured  varicose  vein,  but  in  the  absence  of  such  a  cause, 
they  are,  so  to  say,  always  syphilitic.  It  occasionally  happens  that 
such  a  syphilide  is  found  directly  over  the  knee-joint,  a  position  in 
which  a  varicose  ulcer  never  occurs. 


r 


"^<.aW 


1  \ 


Fig.    434. — Tertiary   syphilitic   ulcers  on  the   right 
leg,  which  is  also  affected  by  severe  varicose  veins. 


Fig.  435. — Same  case  as  fig.  434,  one 
year  later.  Left  leg.  a,  congested  horse- 
shoe shaped  ulcer ;  />,  an  old  puckered  scar  ^ 
c,  cicatrizing  ulcer. 


Fig.  434  illustrates  the  case  of  a  vigorous  peasant  woman  who 
came  to  the  hospital  for  "an  ulcer  of  the  leg."  The  diagnosis  seemed 
obvious,  and  there  appeared  to  be  no  question  of  syphilis.  She  had 
numerous  varicose  veins,  and  had  had  thirteen  confinements  without 
any  miscaiTiage.  But  the  ulcers  were  on  the  upper  half  of  the  leg, 
partially  in  front  of  the  knee,  above  which  was  an  area  of  sharply 
defined  red  infiltration  on  the  point  of  softening.  There  was  a 
puckered  scar  on  the  front  of  the  opposite  patella,which  the  patient  said 
was  due  to  a  similar  ulcer,  cured  ten  years  previously  by  some 
domestic  remedy.     This  of  course  settled  the  diagnosis,  and  iodide  of 


696 


SURGICAL    DISEASES   OF   THE    EXTREMITIES 


potassium  produced  the  anticipated  result.  I  learnt  subsequently  that 
this  patient  had  been  treated  twenty  years  previously  for  recent 
syphihs,  contracted  from  her  fiist  husband.     A  year  later,  this  patient 


Fig.  436. — Cancerous  degeneration  of  ulcer  of  the  foot. 

returned  with  an  ulcer  of  the  left  thigh,  which  is  illustrated  in  fig.  435 
and  seen  to  be  perfectly  characteristic.  The  puckered  scar,  just 
mentioned,  isseen  at  b  in  the  figure.     The  case  illustrated  in  fig.  437, 

came  as  one  of  old- 
standing  "  caries  "  of 
the  foot.  There  was 
nothing  in  the  history 
nn  which  to  base  the 
diagnosis  of  syphilis, 
but  it  was  suggested 
partially  by  the  situ- 
ation and  partially 
bv  the  shape  of  the 
nicer,  and  also  by  its 
yellow  fatty -looking 
base.  This  diagnosis 
was  confirmed  by  tlie 
result  of  treatment. 

It  has  been  stated 
above  that  under- 
mined edges  are  not 
enough  to  arouse  the 
suspicion  of  cancer.  Indeed,  an  ulcer  without  undermined  edges  may 
be  cancerous— although  ordinarily  this  condition  is  an  important  sign. 


Fig.  437. — Tertiary  syphilitic  ulcer  of  the  foot. 


SWELLINGS   AND   TUMOURS   OF   THE    LEG  697 

If  an  old  scar  breaks  down  and  ulcerates — old  scars  have  a  decided 
tendency  to  become  cancerous — and  not  only  refuses  to  heal  but 
actually  increases  in  extent,  this  indicates  a  tendency  to  cancer.  If 
the  ulcer  does  not  become  covered  with  healthy  red  granulations, 
this  constitutes  a  more  important  sign,  and  we  must  entertain  some 
doubt.  If  the  base  constantly  remains  granular  in  appearance  and  if 
the  well-known  little  whitish  plugs  can  be  squeezed  out  of  the  more 
recent  portions,  a  histological  examination  of  a  piece  of  the  margin  is 
demanded  forthwith. 

Sometimes  the  diagnosis  of  cancer  is  not  made  until  the  onset  of 
enlarged  glands  in  the  popliteal  space  and  groin.  This  occurred  in 
the  case  of  a  young  man,  whom  I  saw  while  acting  as  an  assistant.  A 
very  obstinate  ulcer  developed  on  an  old  scar  due  to  a  burn.  The 
3'outh  of  the  patient  disarmed  any  suspicion  of  cancer  at  first.  But 
the  onset  of  enlarged  glands  led  to  a  histological  examination  and 
a  diagnosis  of  cancer  was  made. 


CHAPTER    cm. 
SWELLINGS  AND  TUMOURS  OF  THE  LEG. 

(i)  SwELLiXGS  and  tumours  of  the  leg  present  similar  conditions  to 
those  which  we  have  considered  in  detail  in  connection  with  the 
thigh.  But  the  proportion  of  affections  of  the  soft  tissues  to  tumours 
of  the  bone  is  less  than  obtains  in  the  thigh — if  we  except  ulceration 
and  its  associated  changes.  Otherwise  they  have  no  peculiarities 
specific  to  the  leg.  Perhaps  the  commonest  of  the  tumours  of  the  soft 
tissues  are  the  small  growths  no  larger  than  peas  (tubercula  dolorosa), 
or  the  larger  fibromata  or  neuro-fibrouiata,  which  cause  local  and 
radiating  pains  (fig.  441). 

Sometimes  large  bunches  of  varicose  veins  look  just  like  tumours. 
There  can,  however,  be  no  difificulty  in  diagnosis  if  the  serpentine 
course  of  the  veins  is  visible,  and  if  their  lumen  is  clear,  so  that  slight 
pressure  or  a  change  of  posture  suffices  to  empty  them.  Diagnostic 
interest  centres  around  the  questions  whether  the  veins  belong  to  the 
large  or  small  saphenous  group  and  whether  the  valves  in  the  former 
have  become  incompetent.  Trendelenburg's  sign  is  useful  in  this 
connection. 

The  patient  lies  down,  to  empty  the  veins  of  the  limb.  The  root 
of  the  large  saphenous  vein  is  then  compressed  with  the  finger  and  the 
patient  is  instructed  to  stand  up.     If  the  veins  remain  empty  but  fill 


698 


SURGICAL   DISEASES   OF   THE   EXTREiMITIES 


up  as  soon  as  the  pressure  is   relaxed,  it    is  obvious  that  the  large 
saphenous  vein  is  affected  {cf.  figs,  438a  and  h). 

Even  if  the  veins  are  thrombosed,  the  diagnosis  is  easy,  as  long 
as  separate  serpentine  cords  are  recognizable.  The  beginner  may  be 
uncertain  when  confronted  by  an  isolated  thrombosed  convolution  of 
veins,  looking  like  a  tumour,  but  even  then  the  history  will  give  a  clue, 
and  the  patient  will  probably  have  made  the  diagnosis  already. 


Fig.  4380:. ■ — Varicose  veins,  after  the  limb  has 
been  emptied  of  blocd  and  the  root  of  the  large 
saphenous  vein  is  being  compressed. 


Fig.  438/'. — Same  case,  after  relaxation  of  pressur 
from  the  vein  (Trendelenburg's  sign). 


(2)  Cluiugcs  in  the  bone  are  for  anatomical  reasons  more  accessible 
to  examination  than  in  the  case  of  the  thigh,  and  their  diagnosis  is 
therefore  easier.  We  distinguish  between  tumours  and  inflammatory 
swellings. 

^.—TUMOURS. 

Having  considered  the  diagnosis  of  tumours  in  connection  with 
the  arm  and  thigh,  it  will  be  unnecessary  to  do  more  than  briefly  refer 
to  a  few  forms  which  possess  diagnostic  interest.     The  most  important 


SWELLINGS    AND    TUMOURS    OF    THE    LEG 


699 


of  these  is,  medullary  sarcoma  of  the  upper  end  of  the  tibia,  which 
may  easily  be  mistaken  for  a  somewhat  chronic  osteomyelitis,  more 
especially  as  it  may,  like  all  sarcomas,  raise  the  temperature  and  may 
sometimes  be  very  painful  on  pressure. 

A  girl,  aged  20,  had  been  limping  for  some  weeks,  and  complained 
of  severe  pains  below  the  knee.  The  inner  side  of  the  head  of  the 
tibia  was  sliglitly  swollen  and  very  tender,  but  the  skiagram  revealed 
nothing  characteristic.  We  thought  of  subacute  osteomyelitis, 
particularly  as  the  temperature  rose  in  the  evening  to  101*5°.     ^^  the 


Fig.  439. — So-called  aneurism  of  the  fibula. 
Skiagram  of  the  specimen  obtained  by  operation. 
(Cystic  disease  of  bone.) 


Fig.    440. — Fibro-sarcoma    of  tibia  origi- 
nating in  the  medulla. 


operation,  the  bone  was  found  to  be  surrounded  and  partially 
penetrated  by  a  soft  granulation-like  tissue,  such  as  is  sometimes  seen 
in  chronic  osteomyelitis  ;  but  there  was  neither  pus  nor  sequestrum. 
The  cultures  which  were  prepared  remained  sterile,  and  microscopic 
examination  of  sections  of  the  tissue  showed  the  presence  of  sarcoma. 
This  case  occurred  m  the  early  days  of  skiagraphy.  We  should  now 
conclude  from  the  absence  of  any  bony  thickening  or  of  an  osteo- 
sclerotic zone  around  the  diseased  area,  that  the  case  was  not  one  of 
chronic  osteomyelitis  or  of  tubercle,  but  rather  one  of  new  growth 
{cf.  figs.  439  and  440  with  figs.  446  and  447). 

45 


7CO 


SURGICAL   DISEASES   OF   THE    EXTREMITIES 


Cystic  disease  of  bone  (aneurism  of  bone)  is  indicated  by  disten- 
sion of  the  fibula  or  tibia  to  the  sliape  of  a  beetroot,  by  the  sensation 
of  parchment  crackhng  over  the  bone,  and  probably  by  hearing 
murmurs  over  it  with  a  stethoscope  (fig.  439).  This  condition  is 
possibly  allied  to  sarcomata.  A  medullary  growth  may  in  its  early 
stages  resemble  an  abscess  of  bone,  both  clinically  and  in  a  skiagram 
{cf.  fig.  440  with  fig.  447).  If  the  spindle-shaped  distension  reaches  a 
certain  size,  there  can  be  no  question  of  abscess,  and  the  diagnosis  of 
sarcoma  becomes  clear. 

A  hard  finely  lobulated  tum'mr,  with  sharply  defined  boundaries, 
projecting  from  the  bone,  is  a  chondroma.     The  X-rays  will  usually 

show  that  this  structure  is  composed 
of  cartilage  and  islands  of  bone. 

Cartilaginous  exostoses,  which 
onlv  have  an  external  covering  of 
cartilage,  are  not  of  rare  occurrence 
in  the  leg  (see  Chapter  XCVI). 


Fig.  441. — Neurofibroma  of  the  superficial 
peroneal  nerve. 


Fig.  442. — Chondroma  of  the  tibia. 


B.— INFLAMMATORY    PROCESSES. 

Acute  osteomyelitis  only  requires  brief  notice  because  its 
diagnosis  presents  no  difficulty,  as  the  position  of  the  tibia  is  so  super- 
ficial. It  could  only  be  missed  in  those  rare  cases  wherein  the  patient 
is  intensely  septic  and  semi-conscious,  so  that  he  does  not  complain  of 
the  tibia,  and  a  fatal  result  occurs  before  the  pus  has  reached  the 
surface.  More  interest  attaches  to  the  diagnosis  of  the  stage  of  the 
disease,  and  of  the  anatomical  changes  which  the  operation  may  show. 


SWELLINGS    AND    TUMOURS    OF   THE    LEG  70I 

Fig.  443,  which  represents  acute  osteomyehtis  of  the  long  hollow 
bones,  renders  it  unnecessary  to  enter  into  any  detailed  discvission  of 
these  points. 

The  principal  exceptions  to  the  usual  course  illustrated  in  this 
scheme  depend  upon  the  size  and  the  number  of  the  sequestra.  They 
may  be  flat  or  circular,  single  or  multiple.  The  medulla  of  the 
epiphysis  may  or  may  not  be  involved.  If  one  has  a  clear  conception 
of  the  pathological  processes  which  may  occur,  there  is  no  difficulty  in 
correctly  diagnosing  the  cases  which  run  an  irregular  course. 

The  diagnosis  of  chronic  inflammation  of  the  bone  requires 
more  detailed  consideration,  because  it  is  frequently  missed,  or  is  the 
source  of  great  difficulty.  It  is  important  to  distinguish  between  the 
diffuse  and  circumscribed  varieties  of  this  inflammation. 


(1)   DIFFUSE  INFLAMMATORY  PROCESSES. 

Diffuse  swellings  should  suggest  a  mild  form  of  osteomyelitis, 
which  is  usually  due  to  syphilis,  thus  contrasting  with  what  we  have 
seen  in  regard  to  the  femur.  If  the  disease  is  acquired,  the  diagnosis 
of  gumma  is  established  by  the  presence  of  isolated,  circumscribed, 
and  scattered  inflammatory  areas  on  the  anterior  surface  of  the  tibia 
quite  apart  from  the  history.  In  chronic  osteomyelitis,  the  thickening 
of  the  bone  is  usually  more  diffuse,  which  is  again  a  contrast  to 
gumma  (fig.  444).  Localized  abscesses,  which  heal  up  after  the 
extrusion  of  a  small  sequestrum,  often  occur  in  this  condition.  The 
problem  is,  however,  quite  different  in  the  case  of  children.  Hereditary 
syphilis  of  the  tibia  is  not  usually  of  a  gummatous  nature,  but  is 
recognized  by  diffuse  infiltration  of  the  periosteum,  and  in  its  subse- 
quent course  by  diffuse  thickening  of  the  bone  (fig.  445).  If,  therefore, 
palpation  and  X-rays  demonstrate  a  circumscribed  localization 
(fig.  446),  it  is  an  argument  against  syphilis  and  in  favour  of  osteo- 
myelitis. Syphilis  often  proceeds  just  like  osteomyelitis,  by  means  of 
exacerbations,  but  it  is  differentiated  from  the  latter  by  the  absence  of 
elevations  in  temperature  and  by  its  symmetry.  Obviously  the  history 
is  conclusive.  It  may  be  mentioned  incidentally  that  the  tibia  and  the 
bones  of  the  forearm  are  the  favourite  sites  for  these  lesions  of 
congenital  syphilis. 

A  girl,  aged  7,  suffered  from  periodical  attacks  of  painful  swelling  of 
both  tibiae.  A  diffuse  tender  thickening  of  the  bone  could  be  demon- 
strated (see  fig.  445).  There  was  no  pyrexia.  The  previous  treatment 
had  been  directed  against  tubercular  disease.  The  only  indication  of 
a  syphilitic  heredity  was  the  mother's  statement  that  the  father  occa- 
sionally suffered  from  an  ulcerative  skin  lesion.  Antisyphilitic  treat- 
ment caused  the  symptoms  to  disappear  in  a  very  short  time. 

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SWELLINGS   AND   TUMOURS   OF   THE   LEG 


703 


(2)    CIRCUMSCRIBED   SWELLINGS. 

The    distinction    between    diffuse  and  circumscribed   swellings    is 
obviously  somewhat  arbitrary.    We  include  among  the  latter  only  tliose 
wherein  the  swelling  and  tenderness  do  not  extend  beyond  one  half  of 
tibia,  but  which  definitely  originate 
within  a  much  smaller  compass.    The 
principal   diseases  which   enter  into 
consideration    are    (i)    the    isolated 
^umma,      (2)      the     circumscribed 
chronic      forms     of     osteomyelitis 
(usually    staph3domycosis)    and    (3) 
tubercle,    this    again     in     contrast 
with  the   femur. 

We  have  already  dealt  with  syphilis. 
In  regard  to  the  other  two  diseases, 
the  most  prominent  objective  signs 
are  the  swelling  and  new  bone  for- 
mation in  the  neighbourhood  of  the 
periosteum,  so  that  the  inexperienced 
observer  is  liable  to  be  content  with 
the  diagnosis  of  periostitis.  But  the 
more  carefully  these  cases  are  ex- 
amined and  the  more  often  the 
assistance  of  a  skiagram  is  invoked, 
the  more  frequently  will  we  find 
that  this  periostitis  is  due  to  changes 
in  the  bone  marrow,  either  of  the 
nature  of  an  abscess  or  of  an  area 
of  granulation,  with  or  without 
sequestrum  formation. 

Is  it,  however,  possible  to  tell, 
by  inspection  whether  the  disease  is 
tuberculosis  or  osteomyelitis  ?  It 
must  be  confessed  that  clinical  exam- 
ination often  leaves  us  completely  in 
the  lurch.  We  will  consider  separ- 
ately the  diseases  of  the  diaphysis 
and  the  epiphysis  : — 

{(i)  It  was  previously  assumed  that 
•disease  in  the  diaphysis  could  only  be 
tubercular  if  it  occurred  in  children  ; 

•disease  in  the  diaphysis  in  adults  was  always  considered  to  be  osteo- 
myelitis.   But  as  bacteriological  examination  became  more  frequent,  it 
45B 


Fig.  444. 


-Old  diffuse  osteomyelitis  of 
the  tibia. 


704 


SURGICAL   DISEASES   OF   THE    EXTREMITIES 


was  seen  that  tubercular  disease  occurs  in  the  medulla  of  the  diaphysis 
of  the  tibia.  To  a  considerable  extent,  we  must  depend  upon  the  history 
for  the  distinction.  An  acute  feverish  onset  with  exacerbations  of  the 
same  character  denote  osteomyelitis,  but  these  symptoms  are  not  always 
present.  A  gradual  onset  and  a  gradual  increase  of  symptoms  denote 
tubercle,  but  this  may  also  take  a  sudden  turn  for  the  worse.  The  dia- 
gnosis is  easier  if  the  disease  follows  an  acute  infection  such  as  typhoid 
fever,  scarlet  fever,  &c.  We  shall  probably  be  correct  in  attributing 
the  cause  to  the  organism  of  the  primary  disease  (e.g.,  typhoid  bacillus),, 
or  to  secondary  infection  by  one  of  the  ordinary  pus  organisms.  The 
circumscribed  osteomyelitis  illustrated  in  fig.  446  followed  a  case  of 

whooping-cough. 

If  no  conclusion  can  be 
arrived  at,  either  from  the  his- 
tory or  from  the  rest  of  the 
physical  condition — other  tu- 
bercular or  other  osteomyelitic 
foci — we  must  be  content  with 
the  anatomical  diagnosis,  an 
abscess  of  the  bone. 

If  the  abscess  is  situated 
immediately  under  the  skin,, 
cultures  should  be  made  from 
the  pus  obtained  from  an  ex- 
ploratory puncture,  and  within 
two  days  it  can  be  ascertained 
whether  organisms  of  acute 
suppuration  are  present  or  not. 
If  they  are  not  present  the  case 
is  probably  tubercular.  If  pus 
cannot  be  obtained  without 
operation,  the  bacteriological 
examination  may  be  supple- 
mented by  annual  inoculation, 
if  necessary  even  after  the  opera- 
tion. It  is  our  duty  to  the  patient  not  only  to  open  the  abscess,  but 
also  to  determine  the  nature  of  the  disease,  especially  if  tubercle  is  in 
question.  We  have  already  seen  that  tumours  of  the  medullary  cavity 
may  resemble  chronic  abscess  of  bone,  both  clinically  and  in  a  skiagram. 
(b)  It  has  long  been  recognized  that  disease  in  the  epiyhysis  is  very 
significant  of  tubercle,  and  there  is  always  the  risk  of  regarding  ag. 
tubercle  what  is  really  osteomyelitis  of  the  epiphysis,  in  contrast  to 
what  we  have  already  said  in  regard  to  the  diaphysis.  If  the  history 
and  the  rest  of  the  physical  condition  are  not  conclusive,  we  may  be 
guided  by  the  extent  of  the  periosteal  thickening  in  the  direction  of  the 
adjoining  diaphysis.  If  the  periosteal  thickening  is  very  circumscribed,, 
it  suggests  tubercle  ;  if  it  is  extensive  it  suggests  osteomyelitis. 


(a)  Fig.  445.  {d) 

Periostitis   of   the  Normal    tibia     in 

tibia  due  to  congeni-  child    of    the    same 

tal  syphilis.  age. 


SWELLINGS   AND   TUMOURS   OF   THE    LEG 


705 


Finally,  the  existence  of  a  sarcouiatoiis  new  growth  is  greater  in  this 
situation  than  in  the  diaphysis. 

We  have,  so  far,  been  assuming  that  the  practitioner  has  made  the 
diagnosis  of  some  bone  disease.  But  this  is  not  always  so.  These 
cases  are  often  treated  as  rheumatism,  and  salicylates  or  ointments  are 
given.  Patients  may  thus  wander  for  years  from  one  doctor  to 
another,  and  from  one  quack  to  another,  until  someone  lakes  the 
trouble  to   carefully  compare   one  tibia  with  the  other,  in  regard  to 

palpation  and  tender- 
ness. If  such  an  ex- 
amination reveals  any 
thickening,  however 
slight,  associated  with 


Fig.  446. — Localized  subacute  ostitis  after  whoopinf;-cough. 
A  small  sequestrum  is  seen  in  an  abscess  surrounded  by  a 
sclerosed  area. 


Fig.  447. — Chronic  abscess 
of  bone  in  the  lower  end  of 
the  tibia. 


tenderness  which  has  its  maximum  at  this  area,  and  which  is  the  seat 
of  periodical  throbbing  pains,  severe  enough  to  disturb  the  patient's 
sleep  for  weeks  at  a  time,  we  are  justified  in  diagnosing  an  abscess  of 
bone,  and  we  should  resort  to  the  aid  of  the  X-rays.  In  the  absence 
of  a  skiagram,  the  only  condition  which  may  lead  to  an  error  of 
diagnosis  is  the  pain  caused  by  syphilitic  disease  of  bone. 


706  SURGICAL    DISEASES   OF   THE    EXTREMITIES 

CHAPTER    CIV. 

INJURIES  ABOUT  THE  ANKLE-JOINT. 

In  examining  an  ankle  after  an  injury,  the  most  important  practical 
consideration  is  to  ascertain  whether  there  is  any  deformity  or  not. 
Indeed  we  shah  adopt  the  absence  or  presence  of  deformity  as  a  basis 
of  classification,  although  at  first  sight  it  may  not  appear  to  be  very 
scientific. 

(1)  INJURIES  WITHOUT  DEFORMITY. 

If  the  shape  of  the  foot  remains  normal  after  an  injury,  or  at  any 
rate  is  only  slightly  swollen,  we  may  forthwith  exclude  dislocation 
and  fracture  with  displacement.  This  at  once  limits  the  diagnosis  to 
contusions,  sprains,  or  fractures  without  displacement. 

The  diagnosis  of  contusion  requires  no  detailed  consideration, 
because  it  is  easily  inferred  from  the  nature  of  the  injury  and  presents  no 
difficulty  whatsoever. 

The  diagnosis  of  sprain  is  made  by  exclusion,  just  as  in  the  wrist 
and  elbow  ;  i.e.,  it  can  only  be  entertained  if  it  is  quite  certain  that 
there  is  no  fracture  present.  The  history  is,  however,  often  very 
suggestive.  We  may  diagnose  a  sprain,  if  the  patient,  after  sustaining 
an  injury — not  necessarily  a  severe  one — to  his  ankle,  complains  of 
gradually  increasing  pain  and  tension,  which  do  not  entirely  disappear,, 
even  on  complete  rest.  On  the  other  hand,  a  severe  pain  at  the 
moment  of  the  injury,  which  subsides  when  the  limb  is  kept  at  rest, 
and  which  returns  when  any  movement  is  attempted,  would  a  priori 
suggest  a  fracture. 

The  explanation  is  quite  simple.  Pain  which  is  not  severe  at  the 
moment  of  the  injury,  but  which  gradually  increases  and  does  not 
disappear  in  spite  of  rest,  indicates  an  effusion  of  blood  within  the 
joint — a  circumstance  which  occurs  in  a  sprain.  A  fracture  may  also 
lead  to  intra-articular  effusion,  but  as  the  fracture  opens  up  a  path  for 
the  blood  in  the  surrounding  tissue,  the  effusion  is  under  less  tension. 
The  general  experience  of  fracture  is,  that  the  pain  disappears  when 
perfect  rest  is  maintained  once  the  fracture  has  occurred,  and  that  it 
only  returns  as  a  result  of  movement.  But  it  must  not  be  assumed 
that  all  sprains  present  the  same  clinical  features,  for  in  some,  laceration 
of  the  extra-capsular  structures  is  the  predominant  lesion,  and  the 
pain  therefore  occurs  mainly  on  movement,  just  as  in  fractures. 

Loss  of  power  of  inovenient  is  by  no  means  decisive.  The  beginner 
is  apt  to  diagnose  a  sprain  if  the  patient  is  able  to  walk,  and  to  diagnose 
a  fracture  if  he  is  not  able  to  do  so.  But,  as  a  matter  of  fact,  the 
position  may  be  quite  reversed.  We  often  see  that  a  patient  who  has 
a   subperiosteal    fracture    of   the   malleolus — especially   the    fibula — is 


INJURIES    ABOUT   THE    ANKLE-JOINT 


707 


able  to  walk,  whereas  a  patient  with  a  severe  articular  effusion  will 
anxiously  avoid  the  least  step,  even  if  the  bone  is  not  injured. 

The  localization  of  the  pain  on  pressure  is  of  great  importance  for 
diagnosis.  But  before  proceeding  to  palpation,  we  should  test  the 
pain  produced  by  axial  pressure.  If  this  pain  is  pronounced,  it  indi- 
cates fracture  of  the  tibia  above  the  malleoli,  or  fracture  of  the  tarsus. 
There  is  usually  no  pain  on  axial  pressure  in  simple  malleolar  fractures 
without  displacement.  We  now  palpate  the  joint.  A  diffuse  tender 
sw^elling  over  the  entire  anterior  surface  indicates  an  effusion  of  blood 
under  tension — most  probably  a  sprain.  We  next  examine  the  ends  of 
the  bones  of  the  leg.     If  the  tibia  presents  a  narrowly  circumscribed 


J 


Fig.  448^. — Fractures  of  malleoli  through 
adduction.  Fracture  lines  2  or  3  may 
occur  alone  ;  fracture  line  i  occurs  in  com- 
bination with  2  or  3. 


Fig.  4481^. — Fractures  of  malleoli  through 
abduction.  Frac'ure  lines  2,  4  or  6  may 
occur  alone.  Fracture  line  2  may  occur  in 
combination  with  4  or  6  ;  or  2  may  occur 
with  4  and  5. 


area  of  tenderness  above  the  joint  line,  traversing  the  entire  thickness 
of  the  bone,  it  is  quite  certain  that  a  supra-malleolar  fracture  exists,  or, 
in  a  young  person,  a  separation  of  the  epiphysis  (fig.  45i)-  The 
same  condition  will  usually  be  found  in  the  fibula,  either  higher  up 
or  low^er  down.  If  the  continuity  of  the  tibia  is  unbroken,  we  should 
palpate  the  internal  malleolus.  Circumscribed  tenderness  of  itsextremity 
indicates  that  the  internal  lateral  ligament  is  torn  off  or  lacerated, 
thus  constituting  a  sprain.  If  the  tenderness  runs  transversely  over  the 
malleolus  (fig.  452),  or  obliquely  or  even  directly  upwards  (fig.  450),  we 
must  assume  that  a  fracture  exists,  although  it  may  be  impossible  to 
feel    any   fissure,  sharp  edges    or    false    mobility.      We   examine    the 


7o8 


SURGICAL    DISEASES    OF   THE    EXTREMITIES 


external  malleolus  in  a  similar  manner.  Tenderness  at  its  extremity 
indicates  laceration  of  a  ligament;  tenderness  higher  up  points  to  a 
fracture.  False  mobility  can  be  obtained  much  more  frequently  than 
on  the  inner  side,  but  cannot  always  be  elicited. 


Fig.  449. 


-Adduction  fracture  of  left  internal  malleolus.      (See  fig.  450 
for  skiagram.) 


Fig.  450. — Adduction  fracture 
of  internal  malleolus  (see  fig. 
449).  a — a,  line  of  fracture. 
b — b,  line  of  epiphysis. 


Fig.  451.  —  Slight  cracking  of  Fig.  452. — Fracture  of  external 

fibula  in  classical  position,  with  malleolus,  situated  low   down, 
separation   of   the   epiphysis    of 
tibia  (reduced). 


The  easiest  method  of  detecting  this  mobility  is  to  place  one  finger 
on  the  tip  of  the  malleolus  and  another  on  the  most  tender  spot,  and 
then  to  impart  a  see-saw  movement  to  the  lower  end  of  the  fibula. 


INJURIES    ABOUT    THE    AXKLE-JOIXT 


709 


Indirect  pain  on  pressure  is  another  though  less  constant  sign, 
which  points  to  fracture  of  the  fibula.  This  sign  is  obtained  by 
pressing  the  fibula  against  the  tibia  in  the  middle  of  the  leg.  If  the 
patient  then  feels  a  circumscribed  pain  lower  down,  there  can  be  no 
doubt  about  the  presence  of  a  fracture,  or  at  any  rate  of  a  fissure. 

If  we  are  not  in  a  position  to  confirm  our  diagnosis  by  means  of  a 
skiagram,  confirmation  will  be  derived  from  the  angular  shaped 
ecchymoses  which  form  below  and  behind  the  broken  malleolus,  in 
the  course  of  two  to  three  days.  Similar  ecchymoses  mav,  however,, 
also  appear  after  severe  sprams. 

It  is  of  some  interest,  from  the  points  of  view  of  treatment,  to 
recognize    the   uiode   of  origin    of   tJic  fracture   and    the  position   and 


Fig.  453. — Abduction  fracture  with 
cracking  of  fibula,  in  classical  posi- 
tion. 


Fig.  454. — Torsion  fracture  (spiral  frac- 
ture of  fibula,  with  detachment  of  internal 
malleolus). 


direction  of  the  line  of  fracture.  Fractures  of  the  malleolus  are 
divided  into  those  produced  by  violent  adduction,  by  abduction  and 
by  eversion  of  the  foot. 

In  an  adduction  fracture  the  internal  malleolus  is  always  broken  off^ 
either  in  the  same  plane  as  the  joint  line,  or  in  an  oblique  or  verticallv 
ascending  direction.  A  fracture  of  the  external  malleolus  is  often 
associated  with  it  at  about  the  same  level  as  the  joint  cleft  (figs.  449, 
and  450).  The  fracture  in  the  former  instance  is  produced  by  bending^ 
and  in  the  latter  by  tearing. 

In  an  abduction  fracture  the  internal  malleolus  is  torn  off  near  its 
base  ;  skiagrams  show  that  the  fibula  is  broken  at  what  is  considered 


'lO 


SURGICAL   DISEASES   OF   THE    EXTREMITIES 


to  be  its  weakest  spot,  i.e.,  about  5  or  6  cm,  above  the  tip  of  the 
malleolus.  It  is,  however,  frequently  cracked  much  lower  down. 
There  is  often,  in  addition,  a  detachment  or  a  fracture  of  a  wedge- 
shaped  fragment  of  the  outer  margin  of  the  tibia  (fig.  448  and  456). 
In  fracture  produced  by  torsion  the  signs  are  similar  to  an  abduction 
fracture,  i.e.,  supramalleolar  fracture  of  the  fibula,  sometimes  a  wedge- 
shaped  detachment  of  the  external  margm  of  the  tibia  and  generally 
a  detachment  of  the  internal  malleolus.  The  fracture  of  the  fibula 
does  not,  however,  present  the  appearance  of  a  fracture  produced  by 
cracking,  but  it  is  of  a  spiral  shape  (fig.  454). 

It  is  not  safe  to  base  the  diagnosis  exclusively  on  the  position 
of  the  foot.  The  position  of  adduction  (fig.  455)  is  fairly  conclusive  of 
an  adduction  fracture,  but  abduction  may  be  the  secondary  result  of 


Fig.  455.  — Os  trigonum  (Tj. 


Fig.  456.  — Bi-malleolar  abduction  fracture, 
with  detHched  fragment  frnm  the  outer  side 
of  the  tibia,  and  wiih  subluxation  of  the  foot 
backwards  and  outwards. 


attempts    at   walking,    even     if     the    original     injury    has     been     an 
adduction    fracture. 

Over  excessive  dorsal  or  plantar  flexion  are  rare  causes  of  fracture  ; 
the  former  leads  to  the  detachment  of  a  piece  of  the  anterior 
surface  of  the  tibia  (Lauenstein)  ;  the  latter  leads  to  a  detachment 
fiom  the  posterior  edge  of  the  tibia,  or  its  posterior  surface. 
This  latter  fracture  was  termed  by  French  surgeons,  long  before 
the  Rontgen  period,  "fracture  marginale  posterieure  du  tibia,"  and  it 
has  lately  been  described,  with  the  aid  of  skiagrams,  by  Meissner  of 
Von  Brun's  clinic.  The  fragments  in  both  ca^es  are  usually  trian- 
gular in  form.  The  diagnosis  is  based  upon  the  etiology,  the 
results  of  palpation  and  ihe  .skiagram  (figs.  458  and  460).  Corres- 
ponding fractures  may  also  be  produced  by  the  laceration  involved 
through    reversed    movements.     Leuenbei'ger    has    proved    from    the 


INJURIES   ABOUT   THE    ANKLE-JOINT 


711 


material  in  our  clinic,  that  the  detachment  of  a  fragment  from  the 
posterior  surface  of  the  tibia  is  an  injury  which  occurs  at  about  the 
same  age-period  as  the  separation  of  the  epiphyses,  the  epiphyseal 
line  still  partially  persisting,  i.e.,  from  the  thirteenth  to  the  hfteenth 
year  (fig. -457). 

If  no  lesion  can  be  found  in  connection  with  the  malleolus,  but 
the  patient  nevertheless  complains  of  sharp  pain  as  soon  as  he  puts 
his  weight  on  the  foot,  so  that  walking  is  impossible,  we  must 
palpate  the  tarsal  bones,  especially  the  astragalus,  as  far  as  this  is 
accessible.  An  effusion  of  blood  on  the  anterior  surface  of  the  ankle, 
and  great  tenderness  over  the  head  of  the  astragalus  with  severe  pain 


Fig.  457. — Separation  of  the  epiphysis, 
with  detached  bone  from  the  posterior  surface 
in  a  lad  aged  15. 


Fig.  458. — X,  detachment  of  bone 
from  anterior  margin  of  tibia.  Y-frac- 
ture  of  fibula. 


on  dorsi-ffexion,  render  it  very  probable  that  a  fracture  of  the 
astragalus  has  occurred. 

A  positive  diagnosis  cannot  be  made  without  a  skiagram. 
In  interpreting  it,  however,  it  should  be  remembered  that  a  small 
Wormian  bone  (os  trigonum)  is  occasionally  seen  at  the  posterior 
end  of  the  astragalus  (fig.  455).  This  structure  in  the  early  da^^s  of 
X-ray  diagnosis  was  erroneously  diagnosed  as  a  fracture  (Shepherd's 
fracture).  I  once  had  a  case  wherein  this  os  trigonum  led  to  a 
protracted  action  for  damages. 

Fractures  of  the  os  calcis  are  much  more  frequent.  The  sym- 
ptoms are  such  as  to  differentiate  this  injury  clearly  from  fracture 
of  the  malleolus  or  from  a  sprain.  A  special  section  will  be  devoted 
to  this  subject. 


'12 


SURGICAL    DISEASES    OF   THE    EXTREMITIES 


We  should  not  be  content  with  the  diagnosis  of  sprain  until 
a  careful  examination  of  the  bones  has  yielded  a  negative  result. 
Many  a  case  of  traumatic  flat  foot  and  years  of  persistent  pain 
have  been  the  result  of  an  inaccurate  diagnosis  and  an  untimely 
permission  to  walk. 

Laceration  of  ilie  anterior  tibio-fibular  ligament  ma\'  be  mentioned 
as  a  special  form  of  sprain.  It  is  recognized  by  localized  pain  and 
probably  by  an  effusion  of  blood  above  the  ankle-joint,  between 
the  tibia  and  fibula. 

Another  injury  is  worthy  of  attention,  despite  its  rarity.  The 
patient  himself  probably  hears  a  distinct  crack  at  the  moment  of  the 
accident   and    makes   his    own    diagnosis    of    fracture.     But   neither 

palpation  nor  a 
skiagram  reveal 
such  a  lesion.  The 
tenderness  is  situ- 
ated at  the  poste- 
rior edge  of  the 
external  condyle — 
a  position  which 
is  not  the  seat  of 
pain  in  a  sprained 
foot.  If  the  pero- 
neal tendons  are, 
however,  made 
tense,  it  will  be 
seen  that  they 
move  forwards, 
one  after  the  other, 
over  the  malleo- 
lus, if  indeed  they 
are  not  already 
found  there  at  the 
beginning  of  the 
examination. 
The  case  is  thus  a  typical  dislocation  of  the  peroneal  tendons 
(fig.  459),  and  the  crack  corresponded  to  the  moment  in  which  the 
wall  of  the  tendon-sheath  compartment  yielded  to  the  sudden  and 
sharp  contraction  of  the  muscle. 


Fig.  459. — Dislocation  of  peroneal  tendons,  which   project  like 
cords  over  the  external  malleolus. 


(2)  INJURIES   WITH    DEFORMITY. 

The  diagnosis  of  sprain  does  not  enter  into  consideration  if,  after 
an  injury,  the  shape  of  the  foot  shows  any  deviation  to  one  side  or  the 
other.  The  question  then  arises  as  to  a  fracture  or  a  dislocation 
being  the  cause  of  the  displacement,  or  as  to  the  possibility  of  both 
being  equally  concerned  in  the  injury. 

We  must  first  recognize  the    nature  of    the  deformity.     For  this 


INJURIES   ABOUT   THE   ANKLE-JOINT 


7T3 


purpose  both  limbs  are  brought  into  the  same  position  with  the 
patella  directed  forwards.  We  then  compare  the  direction  of  the  axis 
of  the  leg  and  the  instep  on  either  side,  as  seen  from  the  front,  and  the 
relations  of  the  axis  of  the  leg  to  the  sole,  as  seen  from  the  side.  On 
inspection  from  the  front  we  must  note  whether  the  long  axis  of  the 
foot  forms  an  abnormal  angle  with  the  axis  of  the  leg,  or  whether  it  is 
displaced  parallel  to  its  normal  position.  On  inspection  from  the  side, 
we  must  test  whether  the  axis  of  the  leg  strikes  the  foot  too  far  forwards 
or  too  far  backwards.  If  we  are  in  doubt  about  any  of  these  deviations, 
we  should  see  whether  we  can  cautiously  rectify  any  indication  thereof, 
or,  on  the  other  hand,  whether  we  can  increase  it. 

The  commonest  displacement  of  the  foot  is  posfero-extenial,  wherein 
the  axis  of  the  foot  usually 
makes  with  the  axis  of  the  leg 
an  obtuse  angle,  open  out- 
wards. The  foot  thus  has 
slipped  backwards  and  out- 
wards, and  at  the  same  time 
has  become  tilted  somewhat 
outwards.  The  foot  is  usually 
in  a  condition  of  slight  plan- 
tar flexion  (tig.  460). 

We  start  by  palpating  the 
lower  end  of  the  shaft  of 
the  tibia,  because  the  dis- 
placement just  described  is 
often  caused  by  a  supra- 
malleolar fracture.  We 
then  proceed  to  the  malleoli. 
The  most  frequent  condi- 
tion found  consists  of  an 
abduction  fracture  thereof, 
i.e.,  a  detached  fragment  from 
the  internal  malleolus,  and  a 
fracture  of  the  fibula  due  to 
excessive  bending.  The  as- 
tragalus is  displaced  outwards,  and  the  upper  fragment  of  the  fibula 
rests  directly  upon  it  as  shown  in  the  skiagram  (fig.  456).  At  the  same 
time  the  foot  is  displaced  backwards  in  relation  to  the  leg,  so  that  on  a 
lateral  view  the  tibia  appears  to  project  forwards,  beyond  the  trochlear 
surface  of  the  astragalus  (fig.  460).  Thus  there  is  a  bi-malleolar  frac- 
ture v\/ith  subluxation  of  the  foot  backwards  and  outwards,  and 
displacement  of  the  tibia  forwards  and  inwards.  The  predominance  of 
the  one  or  other  aspect  of  the  deformity  depends  upon  the  nature  of  the 
injury.     The  more  pronounced  the  displacement,  and  the  less  definite 


Fig.  460. —  Bi-malleolar  fracture  with  detachment 
from  posterior  edge  of  tibia  (T),  and  backward  dis- 
placement of  foot  (the  tibia  forwards). 


714 


SURGICAL    DISEASES    OF   THE    EXTREMITIES 


the  fracture,  the  more  justifiable  is  it  to  speak  of  a  dislocation,  without, 
however,  being  able  to  draw  a  hard-and-fast  line  between  the  two 
forms   of  injury.      If  we  feel  both  malleoli  intact,  through  the  skin^ 


Fig.  461. — Dislocation  of  the  foot  backwards. 


and  also  see  the  outline  of  the  bifurcation  of  the  malleoli  projecting 
forwards  (fig.  461),  we  at  once  diagnose  2.  pure  dislocation.  We  may, 
liowever,  still  be  in  error,  because  a  fracture  of  the  fibula  may  exist 

much  higher  up. 

This  occurred 
in  the  case  illus- 
trated in  fig.  462, 
in  a  manner  which 
is  by  no  means 
uncommon  in  the 
present  age  of 
athletics.  The 
patient,  who  was 
devoted  to  sleigh- 
ing, knocked  up 
against  an  obstacle 
with  his  heel,  while 
the  vis  inertiae  of 
his  tibia  continued 
forwards.  Clin- 
ically, the  case 
seemed  to  be  one 
of  pure  dislocation, 
Fig.  462. — Incomplete  posterior  dislocation  of  the  foot.  but    the     skiagram 

showed  that  there 
was  a  fine  subperiosteal  fissure  in  the  middle  of  the  fibula. 

In    other    cases    the    skiagram    shows     (fig.    460)     the    previously 
mentioned  detachment  of  a  piece  of  the  posterior  surface  of  the  tibia, 


INJURIES    ABOUT    THE    AXKLE-JOINT 


715 


with  or  without  separation  of  the  epiphysis,  according  to  the  age  of 
the  patient. 

We  diagnose,  in  a  similar  manner,  the  very  much  rarer  disloca- 
tions and  dislocation-fractures  with  displacement  of  the  foot  to  the 
inner  side  and  forwards. 

It  is  worth  mentioning  that  the  foot  may  be  displaced  forcvanls 
with  the  tibia  resting  on  the  posterior  portion  of  the  trochlear  surface 
of  the  astragalus.     This  gives  rise  to  a  subsequent   deformity  which 

has       been      appropriately 
^  ;       termed      "  Assyrian     foot," 

'       owing    to    its    resemblance 
to       Assyrian       sculptures 

(fig-   463)- 

We  now  come  to  a  very 


Fig.  463. — Bi-malleolar  fracture,  wiih  displace- 
ment of  the  foot  forwards  (old  case,  so-called 
"  Assyrian  foot "). 


Fig.  464. — Dislocation  of  the  astra- 
galus.    (Skiagram  of  fig.  465.) 


different  clinical  picture  of  an  injury,  which  may  present  itself  in 
the  same  anatomical  region.  In  this  condition,  which  occurs  after 
a  severe  injury  to  the  foot,  we  find  a  round  bony  projection  directly 
in  front  of  the  anterior  edge  of  the  tibia,  or  somewhat  to  its  inner 
or  outer  side  ;  the  skin  is  tightly  stretched  over  this  projection,  accord- 
ing to  the  position  in  which  the  foot  is  displaced  in  relation  to  the 
tibia,  either  forwards,  inwards  or  outwards.  These  signs  point  to  one 
diagnosis  only,  viz.,  dislocation  of  the  astragalus,  i.e.,  the  disconnec- 
tion of  the  astragalus  from  all  its  ligaments  and  its  displacement 
46 


7i6 


SURGICAL   DISEASES   OF   THE   EXTREMITIES 


under  the  skin.  It  does  not  matter,  from  the  point  of  view  of  treat- 
ment, whether  the  bone  is  uninjured  or  actually  broken — as  sometimes 
happens.  Fracture  could  only  be  detected  clinically  if  crepitus  is 
distinctly  heard. 

It  is  very  important  to  make  the  diagnosis  of  dislocated  astragalus 

as  soon  as  pos- 
sible, because 
the  stretched 
skin  over  the 
displaced  bone 
may  become 
gangrenous 
within  a  few 
days,  unless 
early  treatment 
is  applied. 

If  we  find 
a  striking  dis- 
placement of  the 
foot  in  relation 
to  tlie  leg,  al- 
though nothing 
wrong  can  be 
detected  in  the 
malleoli,  whose 
relations  with 
the  astragalus 
seem  to  be  nor- 
mal, the  cause 
mav  still  be  a 
dislocation  be- 
low the  astra- 
galus. Such  dislocations  are  extremely  rare,  but  they  may  occur  in 
any  direction.  An  intelligent  inspection  and  palpation  will  easily 
decide  whether  the  foot  is  displaced  forwards,  backwards  or  outwards. 


Fig.  465. — Dislocation  of  the  astragalus  forwards  and  outwards. 
X  =  pr  jection  of  head  of  astragalus;  necrosis  of  skin  beginning 
(formation  of  vesicles). 


CHAPTER    CV. 
FRACTURE  OF  THE  OS  CALCIS. 

A  TYPICAL  fracture  of  the  os  calcis  cannot  be  mistaken  for  any- 
thing else,  and  yet  it  is  an  injury  which  is  frequently  overlooked. 
It  occurs  either  through  the  pull  of  the  tendo  Achillis — a  laceration 
fracture — or  through  its  compression  between  the  astragalus  and 
underlying  surface — a  compression   fracture. 


FRACTURE    OF   THE    OS    CALCIS 


717 


The  term  laceration  fracture  should  be  Hmited  to  the  cases  wherein 
the  fracture  involves  the  tuberosity  of  the  os  calcis,  and  then  only 
if  the  line  of  fracture  run  parallel  to  the  beam  of  the  bone  (fig.  466a)  ; 
or  if  its  course  is  more  oblique  towards  the  plantar  surface,  the  term 
should  be  limited  to  the  cases  wherein  the  fracture  does  not  reach 
as  far  as  the  under  surface  of  the  bone.  All  the  other  fractures  are 
compression  fractures,  whether  they  involve  the  body  of  the  bone  or  its 
anterior  process. 

This  does  not,  however,  justify  us  in  concluding  that  we  can  tell 
the  form  of  the  fracture  from  the  nature  of  the  injury.  Both  laceration 
fractures  and  compression  fractures  of  the  heel  are  usually  due  to 
falls  on  the  sole  from  a  height,  and  it  occasionally  happens  that  both 
forms  of  fracture  occur  in  the  same  bone  (fig.  466).  Clinical  ex- 
amination and  a  skiagram  render  the  differentiation  of  the  two 
varieties  very  easy. 

The  clinical  signs  may  be 
divided  into  four  groups  corre- 
sponding to  four  principal  vari- 
eties of  fractures  of  the  os  calcis. 

(i)  In  fractures  of  the  first 
variety,  occurring  after  a  fall 
from  a  height,  we  find  that  the 
foot  is  not  lower  than  normal, 
that  is  to  say,  that  the  extremities 
of  the  malleoli  maintain  their 
normal  distance  from  the  ground. 
On  the  other  hand,  however,  we 
are  struck  by  a  localized  thicken- 
ing at  the  lower  end  of  the  tendo 
Achillis,  at  the  upper  part  of  the 
tuberosity  of  the  os  calcis.  On 
palpation  the  swollen  area  is 
found  to   be  tender,  but  there  is 

no  tenderness  on  the  under  surface  of  the  os  calcis.  We  may  possibly 
be  able  to  obtain  crepitus.  Pressure  in  the  axis  of  the  leg  is  not 
painful.  The  patient  is  able  to  stand  on  his  foot,  and  even  to  walk 
with  a  certain  amount  of  pain.  If  ecchymosis  occurs,  it  will  be  found 
on  both  sides  of  the  tendo  Achillis.  In  such  a  case  the  localized 
situation  of  the  changes  enables  us  to  make  the  definite  diagnosis  of 
laceration  fracture,  which  is  very  easily  confirmed  by  a  skiagram. 

(2)  In  other  cases  there  is  nothing  abnormal  to  be  felt  at  the 
tuberosity  of  the  os  calcis.  The  distance  of  the  malleoli  from  the 
ground  is  normal,  and  the  heel,  as  seen  from  behind,  does  not  appear 
to  be  broadened.  Nevertheless  the  patient  avoids  putting  any  weight 
on  the  injured  foot.  On  palpation  some  slight  thickening  may  be 
found,  but  there  will  be  a  special  indication  of  pronounced  tenderness 


Fig.  466.— Double  fracture  of  the  os 
calcis.  a,  Laceration  fracture  ;  /■>,  compres- 
sion fracture. 


7i8 


SURGICAL   DISEASES    OF   THE    EXTREMITIES 


Fig.  467. — Double  fracture  of  the  os  calcis.     a,  Fracture  of  the 
tuberosity  of  the  os  calcis  ;  b,  detachment  of  the  anterior  process. 


situated  towards  the  tuberosity  of  the  os  calcis,  or  on  the  plantar 
surface,  or  towards  the  anterior  process.  Pressure  on  the  sole  of  the 
foot  in  the  axis  of  the  leg  is  painful.     The  bruising    usually  occurs 

on  the  sole.  In  such 
a  case  we  should 
think  of  a  com- 
pression  fracture 
iviiJiont  marked  dis- 
placenient  of  tlie  frag- 
ments. 

I'he  skiagram 
shows  either  a  cer- 
tain amount  of  ob- 
literation of  the 
bony  structure,, 
from  which  we 
would  conclude  that 
a  slight  degree  of 
crushing  of  the  in- 
side of  the  OS  calcis 
has  occurred,  or  we 
may  find  distinct 
fissures  running 
along  the  length  of  the  bone  (fig  4666)  and  transversely  to  it.  Detach- 
ment of  the  anterior  process  is  a  special  feature  of  this  injury  (fig.  467). 

These  cases  are 
usually  diagnosed 
at  first  as  sprains 
or  contusions.  It 
is  only  when  the 
patient  attempts  to- 
put  his  foot  to  the 
ground  in  two  or 
three  weeks'  time,, 
and  the  pain  still 
persists,  that  a 
more  severe  form 
of  injury  is  thought 
of.  Palpation  will 
now  reveal  a  dis- 
tinct thickening  of 
the  OS  calcis  by 
callus,  even  in  those  cases  wherein  nothing  abnormal  could  be  found 
on  the  first  examination. 

(3)  The  cases  in  the  third  group  are  much  more  easily  recognized. 
The   heel,   as   seen    from    behind,    is   evidently   broadened    from   the 


Fig.  468.— Severe  crushing  of  the  os  calcis. 


FRACTURE   OF   THE   OS   CALCIS 


719 


very  beginning, 
and  the  malleoli 
are  lower  than  on 
the  uninjured  side. 
The  OS  calcis  is 
felt  to  be  thickened, 
and  is  tender  both 
on  lateral  pressure 
and  on  pressure  in 
the  axis  of  the  leg. 
These  are  cases  of 
comminution  frac- 
tures, which  are 
made  up  of  fissures 
running  lengthwise 
and  also  transverse- 
ly. Obviously  the 
more  accurate  de- 
tails  can    only   be 

made     out     from    a  ^l^:  469--01d    compression    fracture    of  the  right    os    calci., 

treated  as  a  sprain.     The  heel  is  broadened,  the  malleoh  are  low, 
skiagram,      A   trac-       and  the  position  is  one  of  slight  valgus. 

ing  of  the  foot  will 

show  that  it  is  widened  about  the  heel.  Patients  are  sometimes  able 
to  walkabout  even  after  this  injury,  although  the  pain  is  considerable; 
pronation  and  supination  are  particularly  deranged. 


Fig.  470. — Detached  fragment  from  inner  side  of  os  calcis. 

(4)  DetacJuncnt  of  the  sustentaculnin  tali — a  very  rare  condition — 
should  be  thought  of  if  we  find  that  the  foot  is  definitely  in  a  valgus 


720 


SURGICAL   DISEASES   OF   THE    EXTREMITIES 


position,  and  the  region  below  the  internal  malleolus  tender,  without 
the  signs  of  fracture  of  the  malleolus  or  of  the  astragalus,  or  those 
of  an  ordinary  compression  fracture. 

(5)  Finally,  there  may  exist  lateral  detachments  of  bone,  which  are 
only  recognizable  by  the  circumscribed  pain  on  pressure  and  by  X-ray 
examination  from  above,  with  the  foot  greatly  dorsi-flexed  (fig.  470). 

The  following  scheme  briefly  summarizes  the  foregoing  remarks 
on  injuries  about  the  ankle-joint. 


No  striking  deformity,  at 
most  a  little  swelling 


Bone  nowhere  very  tender, 
except  at  attachment  of 
ligaments  to  one  or  other 
malleolus ;  pain  often  per- 
sist?, even  when  at  rest.  No 
pain  on  axial  pressure. 

Tenderness  of  bone  trans- 
versely above  joint  (gener- 
ally on  tibia  and  fibula) ; 
pronounced  pain  on  axial 
pressure 

Great  tenderness  of  or.e  or 
both  malleoli  at  a  more  or 
less  considerable  distance 
above  their  extremities  ; 
false  mobility  not  always 
demonstrable,  but  most 
likely  in  the  fibula  ;  no  pain 
on  axial  pressure. 


'Malleoli  at  normal  level  ; 
pain    over    tuber   cal- 


Tibia   and   fibula   not  tender  I 
on  pressure  ;  pain  on  axial  | 

pressure     (by     pressing    os  I  Ditto,  but  pain  in  body 
calcis   on    iinderlying    sur-"(      of  os  calcis 
face)  usually  present  ;   pain 
on    lateral    compression    of 
the  OS  calcis 


Malleoli  abnormally  low; 
pain  in  body  of  os 
calcis 


Foot    displaced    in    rela- 
tion to  axis  of  leg 


Ditto,   but   pain   on   pressure 
in   the   astragalus   and    not 
,      in   OS    calcis ;    dorsi-flexion 
\     particularly  painful 

/Hone  not  tender;  bifurcation 
between  malleoli  can  be  felt 
under  skin 

Both  bones  tender  trans- 
versely above  the  malleoli 


Bone  tender  above  tip  of  mal- 
leolus (tibia  or  fibula)  or 
above  the  malleolus  (fibula); 
sometimes  accompanied  by 
an  actual  dislocation 

Malleoli  not  tender  ;  bifurca- 
tion between  malleoli  ab- 
normally easily  felt  ;  around 
body  projects,  usually  for- 
wards, under  the  stretched 
skin 

Malleoli  normal  on  palpation  ; 

the      bifurcation      between 

them   not  very  easily   felt ; 

,      considerable      displacement 

\     of    foot   below   astragalus  ; 

head  of  latter  to  be  felt 


Sprain  of  ankle. 


Supra-malleolar  frac- 
ture without  displace- 
ment. 


Malleolar  fracture  with- 
out displacement. 


Fracture   of   tuberosity 
of  OS  calcis. 


Fracture  of  body  of 
OS  calcis  without  dis- 
placement. 

Fracture  of  body  of 
OS  calcis  ;  bones  com- 
pressed. 

Fracture  of  astragalus. 


Simple  dislocation  (foot 
usuallj'  displaced  back- 
wards and  outwards). 

Supra-malleolar  frac- 
ture with  displace- 
ment, before  the  age  of 
14  usuallj'  a  separation 
of  epiphysis  (foot  gene- 
rally displaced  backwards 
and  outwards  as  in  dislo- 
cation). 

Fracture  of  malleolus 
with        displacement 

(foot  generally  displaced 
as  above,  rarely  for- 
wards). 

Dislocation  of  astraga- 
lus (often  combined  with 
fracture). 


Dislocation  below 
tragalus  (occurring 
various  directions). 


INJURIES   TO   THE    FOOT 


721 


Fig.  471. — Compression  fracture  of  scaphoid. 


CHAPTER  CVI. 

INJURIES  TO  THE  FOOT,  IN  FRONT  OF  THE 
ANKLE-JOINT. 

We  need  not  occupy  any  time  over  such  rare  injuries  as  disloca- 
tions of  Choparfs  or  Lisfranc's  joints.  The  displacement  is  so  striking 
that  the  diagnosis  can  be  made  from  anatomical  considerations,  unless 
the  swelling  is  very  great,  in  which  circumstance  a  skiagram  will  be 
necessary. 

More  interest 
attaches  to  certain 
trivial,  but  not  in- 
frequent, injuries, 
which  are  quite 
characteristic, 
and  which  were 
previously  over- 
looked or  incor- 
rectly diagnosed. 
Owing  to  recently 
acquu'ed  know- 
ledge, these  injuries  may  now  be 
recognized  by  their  clinical  signs, 
(i)    Compression     Fracture 

of  Scaphoid. — If  a  person   falls 
from    a   height   on    to    his   toes, 

the    force    is    to    a    great  extent 
gathered  up  by  the  scaphoid  and 

transmitted    to     the     astragalus. 

If  the  scaphoid  is  not  sufficiently 

resistant,  it  becomes  compressed, 

and,  so  to  speak,  is  squeezed  out 

of  the  skeleton   of  the  foot.     It 

then  gains  the  dorsal  surface,  and 

can  be  distinctly  felt  through  the 

soft  parts  (fig.  471). 

In  the  female  sex  a  Wormian 

bone,  described  by  Gruber  as  the 

OS  tibiale  externum,  is  often  found 

on  the  tubercle  of  the  scaphoid 

(fig.  472).     Ignorance  of  this  ab- 
normality has  led  to  the  erroneous 

diagnosis    of    detached  fracture, 


Fig.  472. — Os  tibiale  externum  (T). 


722 


SURGICAL   DISEASES   OF  THE   EXTREMITIES 


when  in  reality  the  pain  complained  of  has  been  due  to  stretching  of 
ligaments,  which  occurs  in  this  situation  through  dancing. 

(2)  Fracture  of  a  metatarsal  bone  is  much  more  frequent.  If  a 
heavily  laden  soldier,  wearied  by  many  hours'  marching,  begins  to 
relax,  and  fails  to  impart  the  necessary  elasticity  to  his  steps  by  the 
proper  use  of  the  muscles  of  his  foot,  it  is  very  easy  for  the  metatarsus 
to  become  overweighted,  and  for  one  of  the  bones — usually  the 
second — to  crack.  The  symptoms  thus  caused  :  spontaneous  pain, 
tenderness  on  pressure,  and  swelling,  were  previously  attributed  to 
inflammatory  changes  in  the  soft  tissues,  until  it  was  shown  that  they 
were  really  caused  by  a  subperiosteal  metatarsal  fracture,  usually 
without  any  dislocation. 


Fig.  473.' — "Swollen  foot."     Old  callus. 


Fig.  474. — "  Swollen  foot."      Recent  callus. 


Sometimes  the  skiagram  which  is  taken  forthwith  reveals  no 
change  at  all,  because  the  fissure  in  the  bone  is  purely  subperiosteal. 
But  in  a  few  weeks'  time  slight  callus  is  visible  in  the  skiagram. 

The  following  is  an  illustrative  case  : — 

A  slimly-built  recruit  showed  the  well-known  signs  of  "swollen 
foot  "  in  the  neighbourhood  of  the  second  right  metatarsal  after  a 
long  march.  The  skiagram,  which  was  taken  immediately,  revealed 
nothing  ;  but  a  diagnosis  of  fissure  was  nevertheless  made.  A  subse- 
quent examination  in  a  few  weeks  revealed  definite  callus.  In  a  few 
months'  time  the  young  man  had  to  resume  his  military  duties,  and 
the  symptoms  returned  in  his  left  foot  after  a  long  march  with  full 


INJURIES   TO    THE    FOOT 


723 


equipment.  On  this  occasion  also  the  skiagram  was  negative,  but 
examination  a  few  weeks  later  showed  the  condition  illustrated  in 
figs,  473  and  474.      The  second  metatarsal   bone  of   the  right  foot, 


Fig.  475. — Fracture  of 
tuberosity  of  fifth  meta- 
tarsal. 


'  _  Fig.  476.— Epiphyseal 
line  at  base  of  fifth  meta- 
tarsal (from  lad  aged  14). 


which  was  injured  first,  presented  a  spindle-shaped  thickenmg  which 
represented  the  remains  of  callus.  The  second  metatarsal  of  the  left 
foot  presented  well-developed  recent  callus.  Before  entering  military 
service  the  patient  had  done  much  mountaineering  without  any  result- 


ed) (^) 

Fig.  477. — Fracture  of  sesamoid  l)one,  seen  from  below  and  from  the  side. 

ing  injury  to  the  bones  of  his  foot,  thus  sliowing  that  the  military 
conditions  are  really  responsible,  i.e.,  the  heavy  equipment  and  the 
forced  marching  of  the  weary  soldier  when  his  muscles  aie  exhausted. 


724  SURGICAL    DISEASES    OF   THE    EXTREMITIES 

(3)  Fracture  of  the  tuberosity  of  the  fifth  metatarsal  bone  is 
also  a  characteristic  injury  of  the  metatarsus.  It  can  be  diagnosed 
clinically,  but  is  easily  overlooked.  It  may  be  caused  by  direct 
violence,  and  probably  also  by  the  contraction  of  the  peroneus 
brevis  ;  it  has  the  appearance  of  a  detached  fracture  (fig.  475).  This 
fracture  must  not  be  confused  with  the  separation  of  the  epiphysis 
(fig.  476),  which  occurs  in  this  situation  between  the  ages  of  12  and  14,^ 
as  described  by  Kirchner  and  Iselin. 

(4)  The  possibility  of  fracture  of  a  sesamoid  bone  (fig.  477)  will  be 
suggested  by  localized  pain  on  pressure  over  the  sole,  and  by  painful- 
ness  of  the  movements  of  the  toes. 

We  need  not  enter  into  details  of  the  numerous  and  varied  frac- 
tures and  dislocations  which  may  occur  about  the  heads  of  the  meta- 
tarsal bones  and  the  toes.  Pressure  and  traction  on  the  separate  toes 
will  always  show  which  of  them  is  involved  ;  but  a  skiagram  will  be 
required  for  further  details. 


CHAPTER    CVII. 
INFLAMMATORY  DISEASES  OF  THE  FOOT. 

.4.— TARSUS. 

Inflammatory  diseases  of  foot  may  be  termed  podartliriiis  on  the 
principle  that  inflammatory  processes  of  the  wrist  are  sometimes  called 
cheir-aiiliritis.  A  general  term  of  this  nature  may  be  justifiable  in  the 
case  of  the  wrist,  because  of  the  small  amount  of  bony  structure  which 
is  involved,  but  in  the  case  of  the  foot  the  diagnosis  must  be  more 
definite. 

We  differentiate  : — 

(1)  ACUTE    DISEASES. 

It  is  usually  easy  to  determine  whether  an  acute  inflammation 
involves  the  ankle-joint,  or  is  situated  more  forwards  in  Ciiopart's 
or  Lisfranc's  joint.  In  the  vast  majority  of  cases  the  ankle-joint 
is  alone  involved,  or  at  least  is  the  principal  seat  of  tfie  affection. 

The  nature  of  these  acute  inflammations  is  similar  to  those  which 
occur  in  the  shoulder  and  knee,  and  as  also  happens  in  these 
joints,  the  original  site  of  the  disease  is  frequently  in  the  adjoining 
bone,  and  not  in  the  joint  itself. 


INFLAMMATORY   DISEASES   OF   THE    FOOT  725 

(2)    CHRONIC    INFLAMMATIONS. 

Tubercle  is,  as  always,  the  most  important  of  the  chronic  inflam- 
mations. Adults  are  more  frequently  affected  with  tuberculosis  of  the 
ankle  than  any  other  joint.  The  patients  usually  complain  of  pain,  of 
a  few  weeks'  or  months'  duration,  about  the  ankle.  There  is  con- 
sequently some  lameness.  There  is  frequently  no  evident  change  at 
this  stage  ;  the  only  sign  of  disease  may  be  a  certain  amount  of  tender- 
ness in  the  region  of  the  capsule  of  the  upper  part  of  the  ankle-joint. 
A  skiagram  may  reveal  nothing  but  a  striking  transparency  of  the 
bone  (fig.  478) — osteoporosis  — due  to  the  disappearance  of  lime  salts. 
If  the  disease  is  somewhat  more  advanced,  there  may  be  swelling  of 
those  portions  of  the  capsule  accessible  to  palpation,  or  there  may 
possibly  be  a  para-articular  abscess.  The  grooves  on  either  side  of 
the  tendo  Achillis  are  very  frequently  obliterated  at  this  stage,  and  the 
tendon  itself  may  appear  to  lie  in  a  depression  (tig.  480).  The  skia- 
gram will  show  that  the  articular  surfaces  are  partially  eaten  away. 
The  mutual  approximation  of  the  bones  indicates  that  the  cartilage 
has  already  to  some  extent  disappeared.  It  may  be  possible  to  detect 
individual  areas  of  disease  in  the  bone. 

We  have  seen,  in  connection  with  the  knee-joint,  how  to  distinguish 
between  primary  and  secondary  lesions. 

When  the  capsule  is  swollen  the  condition  may  be  mistaken  for 
gummatous  disease  or  chronic  gonorrhcEal  effusion. 

1  was  inclined  to  diagnose  syphilis  in  the  case  of  a  young  healthy 
man,  because  the  swelling  was  so  remarkably  painless.  The  history 
was  definitely  against  this  view,  and  I,  therefore,  decided  to  operate. 
I  immediately  alighted  on  gummatous  tissue,  and,  therefore,  desisted 
from  further  interference.  The  patient  made  a  rapid  recovery  under 
iodide  of  potassium. 

If  the  disease  process  has  broken  through  externally,  it  supports  the 
diagnosis  of  tubercle,  as  against  rheumatism  or  gonorrhoeal  arthritis. 
It  is  not,  however,  any  contra-indication  of  syphilis  ;  on  the  contrary, 
it  suggests  tertiary  disease  if  the  appearance  on  the  skin  is  not  that  of 
a  fistulous  orifice,  but  that  of  a  sharply  marginated  ulcer. 

In  the  Tropics  we  may  be  confronted  with  "  madura  foot,"  a 
disease  allied  to  actinomycosis  which  may  give  rise  to  a  clinical  picture 
similar  to  tubercle  or  syphilis. 

In  the  cases  hitherto  discussed  the  principal  feature  has  been 
involvement  of  the  ankle  or  its  neighbouring  joints.  But  we 
frequently  find  that  lameness  and  pain  in  the  foot  may  arise,  although 
the  movements  of  tlie  Joints  are  perfectly  free.  Accurate  examination  will 
show  that  the  tenderness  is  not  in  the  capsule  of  the  ankle-joint,  or 
of  Chopart's  joint,  but  that  it  is  in  the  lower  end  of  the  tibia,  or  the 
OS  calcis,  or  in  rarer  cases  in  the  scaphoid  or  cuboid. 


726 


SURGICAL   DISEASES    OF   THE   EXTREMITIES 


Tubercle  of  the  lower  end  of  the  tibia  may  occur  in  one  of 
three  forms:  (i)  A  simple  central  abscess  of  the  bone,  with  diffuse 
thickening  of  the  cortex ;  (2)  a  lesion  with  a  spongy  sequestrum 
situated  quite  close  to  the  joint ;  (3)  small  areas  of  granulation.  The 
last  applies  to  tubercle  of  the  os  calcis,  which  is  rather  frequent,  and 
which  is  usually  situated  in  its  posterior  half.  We  generally  find  one 
or  more  abscesses  surrounded  bv  sclerosed  bone,  which  often  contains 
large  spongy  sequesti\a.  The  disease  sometimes  remains  within  the 
OS  calcis  for  vears,  and  only  becomes  manifest  from  time  to  time  by 
fresh  inflammatory  exacerbations.     This  intermittent  course  and  the 


Left  (diseased)  side.  Right  side. 

Fig.  478. — Early  stage  of  tubercular  synovitis  ot  the  left  ankle-joint.     The  skiagram 

only  shows  great  osteoporosis. 


skiagram    render    it   easy   to    differentiate    tubercle    from    sarcoma, 
which  has  occasionally  been  observed  in  the  os  calcis. 

It  is  very  important  not  to  confuse  early  tubercle  with  the  so-called 
Achillodynia.  This  term  indicates  a  painful  inflammation  of  the 
mucous  bursa  between  the  tendo  Achillis  and  the  os  calcis — due  either 
to  rheumatism,  gout,  or  gonorrhoea.  It  may  also  come  on,  after 
fatiguing  marches,  and  is  thus  particularly  liable  to  occur  in 
soldiers,  or  in  mountaineers,  who  have  no  kind  of  predisposition 
thereto. 


INFLAMMATORY    DISEASES    OF    THE    FOOT 


727 


Affections    of    the   bursa  snhcalcanca,   and    of    the    bursa    Achillea 
posterior,  which  hes  on  the   tendo  Achihis,   may  occur   under  similar 


v..  J 

J^^m^-\ 

A      M  Mt 

Fig.  479. — Tubercle  of  ankle. 
Narrowing  of  cartilage.  Bone  eaten 
away.  Lesion  in  external  malleolus. 
New  bone  formation  at  X. 


Fig.  480. — Tubercle  of  right  ankle.  Tendo 
Achillis  looks  like  a  furrow  between  the  two 
lateral  swellings  of  capsule. 


circumstances.     Traumatic    or    painful     inflammatory    swellings    are 
sometimes  found  in  the  iendo  Acliillis  itself,  after  long  marches. 


I'lG.  481. — Tubercle  of  left  ankle  (both  feet  are  flat).  The 
grooves  on  either  side  of  tendo  Achillis  are  obliterated  on 
the  left. 


The  pain  produced  by  the  sub-calcaneal  bursa  has  been  incorrectly 
termed  '•'  talalgia."  "  Calcanalgia  "  is  a  more  correct  designation,  but 
^' pternalgia"  is  quite  superfluous. 


728 


SURGICAL    DISEASES    OF   THE    EXTREMITIES 


i?.— METATARSUS   AND   TOES. 

If  the  metatarso-phalangeal  joint  of  the  great  toe  becomes  tender 
oii  pressure,  inflamed  and  spontaneously  painful,  a  typical  attack  of 
gout  is  obvious. 

It  is  of  some  diagnostic  interest  to  recognize  that  a  typical  attack 
may  occasionally  be  followed  by  signs  of  visceral  gout.  In  rare  cases 
the  attack  starts  with  visceral  manifestations,  to  be  followed  by  a  typical 
seizure  m  the  great  toe.  I  have,  for  instance,  seen  a  gouty  subject, 
who  had  been  free  from  attacks  for  ten  years,  suffer  successively  from 
angina,  trigeminal  neuralgia,  gouty  seizure  in  the  foot,  non-purulent 
urethritis,  proctitis,  sciatica,  pneumonia  and  nephritis. 

Acute  phlegmonous  processes  in  the  neighbourhood  of  a  hallux 
valgus  are  generally  due  to  suppuration  in  the  bursa  over  the  head  of 


Fig.   482. — Tubercle  of  os  calcis  (superficial  lesion 
in  bone,  with  sequestrum). 


Fig.  483. — Tubercle  of  os  calcis  (deep  abscess 
in  bone). 


the  metatarsal  bone.  These  abscesses  in  the  foot,  which  are  situated 
under  callosities,  often  assume  the  shape  of  a  stud,  just  as  they  do  in 
the  hand.  They  really  consist  of  two  abscess  cavities,  the  one  being 
under  the  epiderinis,  the  other  more  deeply  situated  under  the  skin,  the 
two  intercommunicating  by  a  narrow  opening. 

If  a  toe  exhibits  signs  of  intermittent  bluish-red  congestion,  with 
pains  not  limited  to  the  discoloured  area,  but  which  may  even  extend 
to  the  leg,  we  should  think  of  commencing  grangrene  in  elderly 
or  diabetic  patients. 

The  considerations  which  apply  to  dactylitis  of  the  hand  and 
fingers  are  also  applicable  to  chronic  inflammatory  processes  of  the 
metatarsus  and  toes.    The  first  metatarsal  bone  suffers  most  frequently. 


DEFORMITIES   OF   THE    FOOT  729 

CHAPTER   CVIII. 

DEFORMITIES   OF   THE   FOOT. 

jMost  deformities  of  the  foot  are  so  easily  recognized  that 
difftcuhies  in  diagnosis  hardly  ever  arise.  We  shall  therefore  only 
refer  to  a  few  points  which  occasionally  perplex  beginners. 

(1)  FLAT  FOOT. 

The  frequency  with  which  a  valgus  foot  and  a  flat  foot  are  combined 
has  given  rise  to  the  impression  that  both  deformities  are  of  the  same 
significance — an  error  which  has  led  to  much  bad  treatment. 

I  once  saw  a  patient  who  had  a  pes  valgus  calcaneus  (figs.  492  and 
493)  provided  by  the  bootmaker  with  a  flat  foot  pad,  although  an 
abnormally  well-developed  arch  was  present,  because  the  practitioner 
had  not  given  any  accurate  instructions. 

Pes  valgus,  or  everted  foot,  is  characterized  by  the  inclination  of 
the  OS  calcis  outwards,  i.e.,  it  is  not  directly  in  the  line  of  the  axis  of 
the  leg,  but  forms  an  obtuse  angle  with  it,  as  seen  from  the  outer  side. 
This  angle  disappears  as  soon  as  the  foot  is  placed  upon  a  corre- 
spondingly inclined  plane  (fig.  484).  The  foot  becomes  flat — pes 
planus — when  the  arch  sinks,  and  the  anterior  part  of  the  foot  at 
Chopart's  joint  becomes  abducted,  so  that  its  axis  deviates  externally 
from  the  perpendicular  to  the  line  connecting  the  malleoli  (fig.  485). 

A  flat  foot  in  the  valgus  position,  with  these  signs,  is  obvious  even 
to  a  lay  observer.  In  such  cases,  the  impressions  made  by  the  sole  of 
the  foot  will  be  of  the  character  illustrated  in  figs.  490  and  491. 
These  severe  cases  do  not,  however,  possess  as  much  diagnostic 
interest  as  those  wherein  the  patient  complains  of  pain  in  various 
places  on  his  foot,  without  the  presence  of  any  definite  flattening  of 
the  arch.  But  careful  inspection  will  often  show  that  the  heel  is 
turned  somewhat  outwards  and  that  the  anterior  part  of  the  foot  has 
undergone  some  lateral  deviation.  The  impression  of  the  sole  may 
nevertheless  be  almost  normal,  or  at  most  show  a  somewhat  wide 
connection  between  the  heel  and  the  balls  of  the  toes  (fig.  489). 

The  pam  is  sometimes  localized  to  definite  spots,  i.e.,  astragalo- 
scaphoid  joint,  the  head  of  the  astragalus,  the  internal  side  of  the 
scaphoid  and  the  area  in  front  of  and  below  the  external  malleolus. 
In  other  cases  the  pain  is  more  diffuse,  extending  over  the  whole 
tarsus,  or  radiating  forwards  between  the  metatarsal  bones.  The  pain 
is  very  sharp  on  standing,  it  is  less  severe  on  walking,  and  it  disappears 
rapidly    on    resting.       Well-fitting   boots   relieve    it ;    low   soft    shoes 


730 


SURGICAL   DISEASES   OF   THE   EXTREMITIES 


Fig.  484. — Bilateral  pes  valgo-planus.  On  ihe  right  side  Fig.  485. — Same  case  from  the  front.  Externa 
the  valgus  position  has  disappeared,  because  foot  is  resting  deviation  of  the  anterior  part  of  foot ;  the  arrow; 
on  an  inclined  plane.  indicate  the  normal  positions  of  the  inner  margin: 

of  foot. 


Fig.  486. — Pes  valgo-planus  on  right  side 
after  traumatic  division  of  the  tibialis  pos- 
ticus tendon. 


Fig.  487. — Same  case  from  behind. 


increase  it.     Occasionally  the  pains  are  felt  as  much  in  the  calf  as  in 
the  foot,  or  even  more  so.     They  may  even  be  felt  in  the  thigh. 

If  one  neglects  to  make  an  examination  in  this  stage,  or  does  so 
only  cursorily,  such  an  unsatisfactory  diagnosis  as  talalgia  or  meta- 
tarsalgia,  &c.,  is  apt  to  be  given. 


DEFORMITIES    OF    THE    FOOT 


731 


Fig.  488. — Normal  foot.  Fig. 


■  Commencing    flat  FiG.  490.— Moderate  fiat  foot, 

foot. 


Fig.  491. — Severe  flat  foot.  Fig.  492. — Pes  calcaneus 

47 


Fig.  493. — Pes  excavatus. 


732 


SURGICAL   DISEASES   OF  THE    EXTREMITIES 


If  the  pains  become  so  severe  that  the  patient  contracts  all  the 
muscles  in  order  to  fix  the  joints  of  the  foot,  the  term  spastic  flat  joot 
is  employed — or  incorrectly,  inflaniuiatoyy  flat  foot. 

It  may  resemble  a  commencing  tuberculosis  in  this  stage.  Flat 
foot  may  accidentally  coincide  with  tubercle.  If  the  first  examination 
is  not  decisive,  the  patient  must  be  instructed  to  rest  for  two  or  three 
weeks.  The  pain  of  fiat  foot  will  then  disappear,  but  that  of  tubercle 
will  either  persist  or  only  abate  in  a  slight  degree. 


Fig.  494. 


-Congenital  absence  of  fibula,  with  pes  valgus, 
in  girl  aged  8  years. 


Fig.  495. — Congenital 
absence  of  fibula ;  skia- 
gram of  fig.  494. 


Errors  of  diagnosis,  such  as  rheumatism,  neuralgia,  &c.,  are  not 
likely  to  be  committed  even  by  the  inexperienced,  if  the  patient  is 
a  young  person  whose  occupation  demands  constant  standing.  On 
the  other  hand  flat  foot  is  frequently  overlooked  in  corpulent  women 
at  the  climacteric  period.  • 

The  increased  body  weight  which  often  sets  in  at  this  age  puts 
loo  great  a  strain  on  the  slender  bony  structure  of  a  woman's  foot. 
It  therefore  sinks  dow-nwards  and  inclines  outw-ards.  The  pains  of  flat 
foot  supervene,   and  they  are  attributed  to   rheumatism,  neuritis,  to 


DEFORMITIES    OF   THE    FOOT 


733 


varicose  veins, 
which  are  usually 
evident,  and  if  they 
are  not,  to  "  deep 
varicose  veins  " 
which  are  usually 
discovered  ad  hoc. 
The  fact  that  the 
pain  is  felt  in  the 
calf  muscles  is  the 
basis  of  this  last 
assumption. 

A  valgus  foot 
or  a  flat  foot,  re- 
sulting from  an 
injury  (fracture  of 
the  malleolus,  os 
calcis,  or  a  meta- 
tarsal bone)  often 
remains  misunder- 
stood for  a  con- 
siderable time,  be- 
cause the  foot  does  not  assume  the  classical  picture  of  flat  foot  from 
the  beginning.  On  the  other  hand,  pes  valgus  may  arise  as  "  habitual 
contracture  "  after  an  injury,  without  any  deformity  of  bone  (fig.  496). 


Fig.  496. — Habitual  contracture  of  left  foot  in  valgus  position, 
after  a  healed  fracture  of  fibula  without  dislocation. 


Fig.  497. — Congenital  clubfoot  (simple 
form). 


Fig.  498. — Habitual  contracture  of  left  foot,  assuming  a  club 
foot  posture,  after  a  sprain  and  completely  healed  fracture  of 
posterior  process  of  astragalus. 


734 


SURGICAL    DISEASES    OF   THE    EXTREMITIES 


Patalxtic  flat  foot  as  a  symptom  of  paralysis,  especially  of  infantile 
paralysis,  is  easily  recognized.  It  resembles  the  flat  foot  which  results 
from  division  of  tendons  (tibialis  posticus,  figs.  486  and  487). 

Congenital  absence  of  the  fibula  is  suggested  by  a  striking  valgus 
posture  with  shortening  of  the  limb  and  curving  of  the  tibia  forwards 
and  inwards.  Palpation  will  show  that  the  external  malleolus  is 
absent.  The  tibia  usuall}^  presents  a  scar-like  stripe,  running  length- 
wise (figs.  494  and  495).  This  mal-development  is  frequently  bilateral 
and  the  fibula  is  absent,  either  completely  or  partially.  The  toes  are 
sometimes  quite  perfect,  at  others  they  are  imperfectly  developed 
towards  the  little  toe.  The  so-called  Volkiuaiin's  subluxation  of  tlic 
foot  outwards  constitutes  a  slight  degree  of  this  deformity. 

(2)  TALIPES,  PES  EQUINUS,  PES  CAVUS,  PES  CALCANEUS. 

These  deformities  are  so  distinctive  where  their  characters  are  once 
known,  that  we  may  be  content  with  a  few  typical  illustrations.     The 

cause  of  these  deformities  is,  howevei", 
of  importance,  from  the  therapeutic 
standpoint.  Whereas  in  flat  foot  the 
mechanical  and  rachitic  changes  pre- 
dominate over  those  of  paralytic  or 
congenital  origin,  the  deformities  at  the 
head  of  this  section  are  mainly  due  to 
congenital  or  paralytic  causes,  rarely  to 
injuries  and  never  to  rickets.  The  first 
question  in  regard  to  equinus  must  be 
in   regard    to    its  congenital   or  acquired 

\  ^  ^  origin.     The  history  usually  supplies  the 

answer.  If  not,  we  may  assuine  a  para- 
lytic or  acquired  origin  if  there  is 
coldness  or  blueness  of  the  foot,  and 
obviously  also  if  definite  paralysis  exists. 
Atrophy  of  the  calf  muscles  is  of  itself 
not  conclusive  evidence,  because  this 
may  also  arise  in  course  of  time  from 
want  of  activity  of  certain  muscle  groups 
as  a  result  of  congenital  club  foot,  and 
may  indeed  reach  a  very  considerable 
degree.  Neither  does  the  unilateral  or 
bilateral  existence  of  the  deformity  give 
any  information  on  this  point,  because 
the  congenital   and   the  acquired   forms 

may  both  affect  either  one  or  two  sides.     But  if  it  once  be  ascertained 

that  the  talipes  is  of  the  paralytic  variety,  certain  important  conclusions 

as  to  the  cause  of  the  paralysis  follow  therefrom. 


Fig.  499.  —  Paralytic  pes  equinu? 


DEFORMITIES    OF    THE    FOOT 


73; 


Unilateral    talipes  with  flaccid  paralysis  is  usually  due  to  acute  an- 
terior poliomyelitis,  but  may  exceptionally  be  the  result  of  spina  bifida. 
The   latter  cause  is  suggested    by  the  simultaneous   existence    of 


Fig.  500. — Paralytic  pes  cavus  in  a  case  of  spina  bifida. 

disturbances  of  sensation  and  incontinence  of  urine.     If   no  swelling 
is    evident   on    the    back,  a    spina   bifida   occulta   should    be   looked 
for.     Similarly,   bilateral  talipes  with  flaccid  paralysis  should  suggest 
some     congenital    defect    in 
the  lumbar  cord.  ^ 

Unilateral  talipes  com- 
bined with  spastic  paralysis 
is  due  to  infantile  cerebral 
paralysis,  but  is  in  excep- 
tional cases  the  result  of  an 
injuiy  to  the  brain  (see  false 
meningocele).  If  both  feet 
are  aft'ected  with  talipes  and 
spastic  paralysis,  we  may  as- 
sume that  the  cause  is  Little's 
disease,  the  pathology  of 
which  we  cannot  here  dis- 
cuss. 

The  spastic  forms  of  club 
foot  are  classified  as  acquired, 
although  their  ultimate  cause 
is  congenital.     The  development  of  the  deformity  does  not,  however, 
occur  until  post-foetal  life. 

One  form   (jf  talipes  deserves  special  mention  because  it  plays  an 
imp(jrlant  part   in    the   considerati(jn    of  accidents,   i.e.,   the   so-called 


Fig.   501. -Pes  calcaneus  of  slight  degree,  con- 
genital origin. 


736 


SURGICAL    DISEASES    OF   THE    EXTREMITIES 


hahit  contracture.  If  for  some  reason  or  other,  generally  an  injury, 
the  movements  of  the  ankle  and  Chopart's  joint  become  painful,  these 
joints  are  held  rigid  by  muscular  fixation  so  that  the  foot  does  not 
yield  at  all  on  walking,  but  is  planted  down  stiffly  on  its  outer  edge, 
as  in  talipes.  If  the  patient  is  very  sensitive  to  pain,  or  has  neuro- 
pathic tendencies,  or  if  there  be  a  question  of  compensation  involved, 
this  posture  may  persist  after  the  disappearance  of  the  pain  or  after 
the  recovery  from  the  injury  ;  it  becomes  a  habit  contracture. 

I  have  seen  a  habit  contracture  of  this  kind  come  on  after  a  con- 
tusion of  the  foot.  Although  there  was  not  the  slightest  anatomical 
change,  the  foot  was  always  held  in  the  talipes  position  on  walking. 
The  muscles  of  the  whole  limb  were  somewhat  atrophic,  and  there  was 
some  cyanosis  due  to  the  deficient 
muscular  activity.  The  condition  had 
been  present  for  three  years  owing  to 
the  protracted  legal  proceedings. 

The  preceding  remarks  on  ordinary 


Fig.  502. — Hallux  valgus  of  various  degrees. 


Fig.  503. — Hammer-toe  (second). 


talipes  apply  also  to  pes  equinus,  pes  calcaneus  and  pes  cavus. 
These  varieties  may  be  either  congenital  or  acquired,  and  in  the  latter 
case  are  usually  of  paralytic  origin.  Bilateral  pes  cavus  and  some- 
times also  pes  calcaneus  may  gradually  develop  in  advanced  infancy 
or  at  puberty,  without  any  definite  ascertainable  cause. 

It  is  probably  due  to  some  congenital  disturbance  of  the  co- 
ordinating power  of  the  various  muscle  groups,  and  may  be  a 
very  slight  sign  of  some  hereditary  mal-development  of  the  spinal 
cord,  such  as  defective  development  of  certain  anterior  horn  cells. 


DEFORMITIES   OF   THE    FOOT 


737 


Fig.  499  shows  that  pes  equinus  may  be  mistaken  at  first  sight  for 
hip  disease. 

(3)  DEFORMITIES  OF  THE  TOES. 

Many  an  elegant  shoe  conceals  deformities  which  not  only  offend 
the  aesthetic  taste,  but  which  also  make  the  life  of  the  wearer  a  torture, 
until  the  patient  decides  to  part  with  the  toe  or  to  permit  a  resection 
of  the  deformed  joint. 


Fig.  504.— Hallux  valgus.    Skiagram  of  fig.  502.         Fig.  505.  — Hallux  valgus.    Skiagram  of  fig.  502. 


This  is  especially  true  of  the  deformity,  which  is  a  product  of 
civilization,  known  as  hallux  valgus.  A  glance  at  the  two  degrees  of 
tlie  deformity,  as  depicted  in  figs.  502,  504  and  505,  suffices  for  the 
purposes  of  diagnosis.  We  have  already  referred  to  the  secondary 
inflammation   of  tlie  bursa  which  may  ensue. 

Hammer  toe  (fig.  503)  is  another  frequent  deformity.  It  may  be 
due  to  hereditary  disposition,  as  well  as  to  badly  htting  boots.  When 
this  condition  gives  rise  to  pain,  it  is  mainly  the  result  of  inflammation 
of  the  bursa. 


738 


SURGICAL    DISEASES    OF   THE    EXTREMITIES 


CHAPTER   CIX. 
TUMOURS  AND  ULCERS  OF  THE  FOOT. 

AlAXY  different  forms  of  tumours  and  of  ulcers  have  been  observed 
on  the  foot,  as  on  the  hand,  but  there  are  very  few  characteristic 
enough  to  deserve  mention. 


Fig.    506. — Multiple    chondromata    of    the  toes  (from  the  surgical 
clinic,  Berne). 


Fig.    507. —  Cutaneous  horn  on 
heel. 


Fig.  508. — Cavernous  angioma 
of  foot. 


(1)  TUMOURS. 

Chondroma  of  the  toes  is  the  most  important  of  the  innocent  new 
groivilis,  and  its  character  is  similar  to  that  of  chondroma  of  the 
fingers  (fig.  506). 


TUMOURS    AND    ULCERS    OK    THE    FOOT 


739 


If  a  toe-nail  is  gradLially  raised  by  a  tLunoiii"-like  structure  beneath 
it,  a  sub-ungual  exostosis  is  suggested,  as  already  described  by 
Dupuytren.  Fibromata  originating  in  the  nail-bed,  and  growing  under 
or  close  to  the  nail,  are  rare.  Cutaneous  horns  (fig.  507)  are  also 
unusual. 

Lipomata  have  been  seen  on  the  metatarsus  and  they  are  liable  to 
spread  between  the  bones  and  plantai-  aponeurosis.  Cavernous 
angiomata  of  congenital  origin  also  occur  on  the  foot. 

Although    these   are    histologically  innocent,   they   invade  various 
tissufs    such   as  skin,   muscle    and    tendons,    and    the}'    may    lead    to 
profound    disturbances    therem.       Their    granular    surface,  and    their 
translucent  bluish-red  colour,  and  their 
emptying  on   piessure   are  signs  which 
render  them  immediately  recognizable. 
Fig.  508  is  a  tvpical  illustration  of  the 
appearance  of  a  cavernous  angioma  in 
general. 

Sarcoma  of  the  os  caicis  is  the 
only  mallgnani  iuiuour  which  is  at 
all  characteristic  in  this  region.  Its 
diagnosis  from  tubercle  has  already 
been  discussed. 


(2)   ULCERS. 

In  addition  to  the  well-known  tiiad 
of  ulcers  —  tubercular,  syphilitic  and 
malignant — the  foot  presents  frequent 
examples  of  "perforating  ulcer"  and 
of  circumscribed  gangiene  of  the  skin. 
The  nature  of  the  ulcer  can  generally 
be  diagnosed  from  its  situation.  In  the 
dorsum  they  are  usually  tubercular  or 
syphilitic  (fig.  437),  rarely  lualignant. 
The  recognition  of  syfthilis  and 
of    tubercle    has    been    dealt    with    in 

Chapter  CII.  A  malignant  ulcer  is  ditferentiated  from  both  of  these 
by  its  papillomatous  appearance,  or  by  its  hard  edge  and  base.  If  we 
find  a  discoloration  of  the  skin,  either  circular  or  map-hke  in  shape,, 
towards  the  toes,  associated  with  loss  of  sensation  in  the  ailected  area 
and  with  neuralgic  pains,  we  must  diagnose  commencing  gangrene 
and  should  examine  for  arterio-sclerosis,  diabetes,  or  nephritis. 
Alcohol  and  syphilis  may  be  indirect  causes,  if  the  patient  is  young. 
The  gangrene  becomes  quite  definite  in  the  course  of  two  or  three 
weeks,  the  area  involved  becomes  black  and  sloughs  away  from  the 
healthy  skin.  The  condition  of  the  arteries  and  of  the  general 
48 


Fig.   509. — Fcif  raim^   ulcer  due  to 
alcoholic  neuiiii.s. 


740  SURGICAL     DISEASES     OF     THE     EXTREMITIES 

circulation  determines  whether  the  process  ceases  with  this  circum- 
scribed destruction,  or  whether  it  is  merely  the  prelude  to  an 
ascending  gangrene. 

An  ulcer  on  the  sole  is  either  malignant  or  of  a  neuro-paralytic 
nature.  The  latter  (perforating  ulcer)  is  diagnosed  from  its  situation 
on  parts  especially  subjected  to  pressure,  such  as  the  heel,  the  ball 
of  the  great  or  little  toe,  by  its  slight  local  painfulness  and  its 
associated  disturbed  sensation  and  anaesthesia,  often  combined  with 
radiating  pains.  These  pains  are  not  accidental  accompaniments, 
but  are  indicative  of  the  cause  of  the  malady,  i.e.,  of  a  neuritis.  The 
margin  of  the  ulcer  is  formed  of  thickened  epithelium,  and  the  central 
necrosis  may  extend  to  the  tendons  and  bones.  Attacks  of  phleg- 
monous inflammation  around  the  ulcer  are  very  characteristic  of 
the  condition. 

Sometimes  an  injury  to  a  peripheral  nerve  accounts  for  the 
perforating  ulcer,  but  it  is  more  frequently  the  result  of  the  nerve 
disturbances  which  follow  on  spina  bifida,  or  of  some  disease  of  the 
spinal  cord  or  cerebral  system,  such  as  syringo-myelia,  tabes  dorsalis 
or  general  paralysis.  Alcoholic  neuritis  is,  however,  the  most  frequent 
cause. 

Ulcers  due  to  circumscribed  gangrene  in  arterio-sclerotic  and 
diabetic  subjects,  as  noted  above,  must  not  be  confused  with  per- 
forating ulcer.  The  former  occur  usually  on  the  dorsum  of  the  foot 
and  toes,  and  are  attended  by  severe  neuralgic  pains.  Of  course, 
it  is  quite  possible  that  a  genuine  perforating  ulcer  may  also  develop 
in  these  patients. 

If  an  ulcer  forms  on  a  part  of  the  sole  not  subject  to  pressure 
it  may  be  an  epithelionna,  which  is  rare,  or  a  sarcoma  of  the  skin, 
which  is  still  rarer. 

Finally,  reference  must  be  made  to  the  ulcerative  processes  in 
the  vicinity  of  the  toe-nails.  Ingrowing  toe-nail  is  so  familiar  that 
it  hardly  requires  mention  from  the  diagnostic  aspect,  were  it  not  that 
syphilitic  and  tubercular  ulcers  also  occur  at  the  same  spot.  The 
latter  is  sometimes  termed  onychia  maligna.  Syphilis  is  diagnosed 
from  the  history,  Wassermann  reaction,  and  the  results  of  specific 
treatment.  Tubercle  is  diagnosed  if  the  treatment  for  ingrowing 
toe-nail  and  for  syphilis  fail  to  cure  the  ulcer;  but  it  is  a  better  plan 
to  remove  a  small  piece  of  the  margin  for  the  purpose  of  histological 
examination. 


INDEX. 


Abdomen,  surgical  diseases  of,  235 

— ,  injuries  of,   244 

— ■  - -,   Avith  external  wound.  251 

— ■  — ,   without  external  wound,  244 

Abdominal  cavity,  acute  inflammation 
in,  254-276 

—  — ,  effusion  of  bile  into,  in  injuries 
of  liver,  247 

,  entrance  of  gas  into,  in  rup- 
tured intestine,  245 

,  m       perforation 

of  stomach,  298 

,  tumours   in,    demonstration    of, 

287-290 

,  by   exploratory  puncture, 

291 

--  hernia,  epigastric,  369,  370 

--  injuries,  gunshot,  252 

—  integument,  abscess  of,  272,  369 

—  — ,  actinomycosis   of,   377 

,  fibroma  of,  374,  375,  376,  2,17 

,  tenderness    of,     in    peritonitis, 

258,  259 

,  tumours  of,  287,  368-376 

,  atypical   positions,   376 

— in  inguinal  region,  374 

lumbar  region,  375 

—  umbilical   region,   371 

_  . upper  abdomen,  368 

—  lipoma,  subcutaneous,  369,   376 
— •    muscle,  tuberculosis  of,  376,  2>n 

—  nsevi,  sarcomatosis,  214,  376 

—  rigidit}-,      reflex     after     intestinal 
injuries,  246 

,  in  peritonitis,  258,  275 

—  sinuses,  jin 

—  —  in  groin,   379 

—  —  at   umbilicus,  zil 

—  tumours    caused    by    inflammatory 

changes,  287 
■ —  — ■  causing     intestinal     obstruction, 
287 


Abdominal  tumours,  consistence  of, 
289 

,  determination      of      origin      of 

those  which  fill  up  entire  abdomen, 
289 

— •  — ,  innocence  and  malignancy  of, 
290 

,  movable,  288 

,  phantom,  287 

— •  — ,  slightly  movable  and  not  very 
extensive,   289 

,  type  of  displacement  of  un- 
paired organs,  236 

—  viscera,  diagram  of  parts  felt  on 
palpation,  240 

displacements,  235;   congenital, 

235  ;   acquired,  237 

—  wounds,  perforating  and  incised, 
253 

Abducens  nerve  (6th),  focal  symptoms 

in  lesion  of,  40 
,  paralysis    of,     in    fractures    of 

base  of  skull,  5 
Abrasion        fracture        of        eminentia 

capitata  humeri,  565,   567 
Abscess,       ai:)pendicular,      335,       336; 

position  of,  334 

—  — ,  diagnosis  from  hip  disease,  652 

•  —  — ,  peritonitis,  262,  272,  273 

— ,   Bezold's,  ZZ^    133 

— ,  cerebellar,  32 

— ,  epidural,  30 

— ,  epigastric,  368,  369 

— ,  gluteal,   519 

- -,  inguinal,    517,    518 

,  meso-coeliac,   diagnosis   from  peri- 
tonitis, 264 

—  -    of  abdominal  wall,  274 
— ■    axilla,  211 

—  brain,  18 

■ — ■  — ,   diagnosis,  17,  18 

,  etiology,   19,  20 

,  symptoms,   17,   18,   19 

—  breast,  220,  221 


742 


INDEX 


Abscess,  breast,  superficial,  221 

—  kidney,  447,  452 

—  liver,  265,  326,  327 

—  lumbar  region,  375,   517 
--    lung,    195,    ig6 

,   diagnosis    from    bronchiectasis, 

198 

—  neck,   134,   135,  517 
— ■  — ,  chronic,   134,   135 
,  due  to  caries,  518 

,  tubercular   (cold),   134,   135,   138 

—  palate,  95 

—  pelvic  bones,  517 

— ■    seminal  vesicles,  431 

—  spleen,  266,  330 

—  supra-clavicular  fossa,  133 
— •    supra-symphysis  pubis,  272 

—  temporal  lobe,  30,  31 

—  tibia,  lower  end,   705 

— ,  peri-articular,  of  foot,  725 

knee,  679 

— ,  perineal,  519 

— ,  peri-nephritic,       tubercular,       375, 

442 
— ,  peri-proctal,  410 
— ,  pharyngeal,  96 
— ,  posterior  cervical,   133 
— ,  prostatic,  431,  471 
— ,  residual,    in    peritonitis,    256,    268, 

336 
— ,  retrobulbar,  50,  61 
— ,  retromammarj-,  219 
— ,  retroperitoneal,  266,  335 
— ,  retropharyngeal,  gi,  114 
— ,  retrotonsillar,  91 
— ,   submental,   131 
— ,   subphrenic,   iqs,  276 
,  in  appendicitis,  J,2>^ 

—  — ,  with  pleural  exudation,  279 

,  without  pleural   exudation,   277 

— ,  sub-umbilical,  272,  378 

— ,  tubercular   (cold),  of  skull,  56 

of  spine,    135,  215,   515,   516 

Accessory  goitre,  96 
,  true  and  false,  150 

—  thyroids,     malignant     growths    of, 

171 
Acetablum,  fractures  of,  617 
— ,  displacement    of,   in    hip    disease, 

649,  650,  653 
Achillodynia,  726 
Acne  pustules  of  axilla,  211 
Acromegaly    in    tumours   of    pituitary 

body,  24 


Acromio-clavicular   joint,    injuries   of, 

535,  536 
Actinomycosis     of    ileo-csecal     region, 

288,"377 

—  jaw,  78,  79 

—  limbs,   571 

—  lungs,   198,  210 

—  mamma,  222 

—  neck,   13s,   140 

— •  — ,  with   sinus  formation,    136 

—  tongue,   107 
Adamantinoma,   87 

Adenoids  of  roof  of  pharynx,  gi 
Adenoma  of  liver,  326 
— ,  testicle,  422 
-Adiposis  dolorosa,  24,  175 
Air-goitre,  nature  of,  141 
Air  passages,  diseases  of,  chronic,  118 

■  — ,   surgical,    no 

,  foreign  bodies  in,    116,    117 

— •  — ,  injuries   of,    116,    189 
x\lbuminuria  in  diphtheria,   113 
Alveolar  process,  haemorrhage  in  frac- 
ture of  upper  jaw,  tj, 

—  tumours,  85 

Anaesthesia     dolorosa     in     tumours    of 
jaw,  84 

—  paralysis,  of  upper  limb,  594 
x\nal  region,  iistulse,  410,  424,  425 
,  complete     and     incomplete, 

426 

■ ,  nature  of,  426 

,  injuries   of,  412,   413 

,  prolapse  of,  411,  412 

,  tumours  of,  409-412 

Anarthria,      diagnosis      and      surgical 

significance  of,   46 
Aneurism,   cirsoidal,   of   face,   64 

—  of  aorta,  201,  205 

— ■  — ,  penetrating      through      thoracic 
wall,  213 

—  carotid,   163 

—  fibula,   690 

—  innominate  artery,  203 
— •    neck,    127,    162 

,   arterio-venous,    164 

,   diagnosis    from    other    tumours 

of  neck,  140,  163 

—  thigh,  658 
— ,   femoral,  658 
— ,  ophthalmic,   50 
— ,  popliteal,  687 
— ,   subclavian,    163 

Angina,   diffuse  and  unilateral,  90,  91 


INDEX 


743 


Angina,  dysphagia  in,   123 
— ,   Ludovici,    132 
— ,  Ludwig's,  90 
Angioma  of  arm,  572 

—  face,  63,  64,  66 

—  foot,  738,  73Q 

—  hand,  600 

—  longitudinal  sinus,   53 

—  mouth  cavity,  g4 

— ,  mulberry-like,  of  infant,  54 

—  orbit,  56 

—  sacral  region,  485 

—  scalp,  51,  52,  S3,  54 

—  thigh,  657,  658 

—  thoracic  wall,  216 

—  tongue,   105 

Ankle,  contusions  of,  706 

— ,  dislocations  of,  714,  715 

— ,  fractures  of,  706,  709,  710 

— ,  gonorrhoeal  effusion  of,  725 

— ,  injuries  of,   with   deformity,   712 

,  without  deformity,   706 

,  summary  of,  720 

— ,  sprain  of,  706,  710 

— ,  tuberculosis  of,  726,  727,  728 

Ankylosis  of  hip-joint,  655 

—  jaw,  causes,  76,  77 
— -    knee-joint,  686 

—  vertebral  joints,  521 
Anuria,  427,   443 

Aorta,     aneurismi    of,     201,     202,     203, 

205 

,  skiagraphy  in,   203 

,  diagnosis     from     tumour,     201, 

287 
Aphasia,  focal  diagnosis  of,  46,  47 

—  in  cerebral  abscess,  30 

■ cerebral  pressure,   14 

Appendicitis,  266,  272,  332 

— ,  chronic,  262,  339,  345,  346 

— ,  complications,    336,    :i37 

— ,  condition   of    vermiform    appendix 

and     its     surroundings     in     early 

stages  of,  332 
— ,  diagnosis  of,  332 

in  the  intervals,  338 

,  from  abdominal   tumour,   288 

cholecystitis,  317 

—  -  —     hip  disease,  652 
peritonitis,  267 

ruptured  tubal  pregnancy,  273 

.    urinary   tuberculosis,   460 

— ,  diagram  of  its  most  important 
forms,  and  some  diseases  con- 
cerned in  differential  diagnosis, 
268-271 


Appendicitis,  exploratory  puncture  in, 

336 
— ,  history  of,  272,  338 
— ,  ileus  in,  337,  354 

—  in  hernial  sac,  401 

— ,  pregnancy  and  puerperal  period, 
276 

— ,  larval   (Ewald),  338 

— ,  physical   signs,   338,  33Q 

— ,  position  and  extent  of  appendix 
abscess,  334,  335 

— ,  residual  abscesses  and  their  sig- 
nificance,  334,  2,3^ 

— ,   symptoms  in   localized   peritonitis, 

333 
^  —    in  early  stage,  332 

—  —    when   accompanied   by   general 

peritonitis,  333,  334 

—  with  peritoneal  symptoms,  264,  333 
Appendix     vermiformis,     abscess     of, 

272,  333 
,  displacement  of,  237,  317,  318 

—  — ,  its  condition   and   surroundings 

in  early  stage  of  appendicitis,  33^ 

,  palpation  of,  239 

— •  — ,  position  of,  334 

Arm,  chondroma  of,   576 

— ,  fibroma  of,   576 

— ,  gumma  of,  574,  575,  576 

— ,  mobility      in     injuries     of     spinal 

column,  490 
— ,  muscular  angioma  of,  572 
— ,  muscular  tuberculosis  of,  573 
— ,  myositis  ossificans  of,  574 
— ,  neuroma  of,   572 
— ,  osteoma,  traumatic,  of,  574 
— ,  osteomyelitis  of,  575,   576 
— ,  posture  of,  in  transverse  lesion  of 

spinal  cord,  491 
— ,  sarcoma  of,  576 
— ,  tuberculosis  of,  573,  575,  576 
Artery,    femoral,   aneurism  of,  658 
— ,  mesenteric,  embolism  of,  264 
— ,  ophthalmic,  aneurism  of,   50 
Arthritis,  acute,  of  elbow,   569 
— ,  deformans  589,  590,  591 

—  of  foot,  724 

—  hip,   643,  644,  646 

—  jaw,   76 

—  — ,  ankylosing,   77 

—  shoulder,   550 

—  vertebral  joints,  causing  chronic 
deformity,  521 

—  wrist,    588 

,  tubercular,  589,  590,  591 


744 


INDEX 


Articulation,  sacro-iliac,  sprain  of, 
630 

—  . ,  fissure  in  neighbourhood  of, 

630 

Ascites,  chylous,  in  old  umbilical 
hernise,  Z12, 

,  diagnosis  from  exu- 
dative tubercular  peritonitis,  283 

Assyrian  foot,  715 

Astragalus,   dislocation  of,   715 

— ,  fracture  of,  711 

— ,  injuries   of,   715 

Auditory  nerve  injuries  through  frac- 
tured base,   5 

,  focal      symptoms     in, 

44,  45 
Axial  rotation  of  intestine,  364,  365 
Axilla,    abscess   of,    due   to   acne   pus- 
tules or  furuncles,  211 
— ,  enlargement  of  glands,  210,  211 

,  in  cancer  of  breast,  22g,  230 

— ,  hydro-adenitis  of,  211 

— ,  lymphadenitis  of,  550 

-— ,  pendulous  lipoma  of,   572,  573 

— ,  phlegmon  of,  210,  211 


B 


BACILLURIA,    434  — 

— -    in  cystitis,  465  — 

Back,   fiat,   525  — 

— -,  mobility    of,     after    vertebral    in-      — 

juries,  4Q0  — 
— ,  muscles  of,  fibro-lipoma  of,  216  — 
,  fibroma,    lipoma,    and   sarcoma      — ■ 

of,  218  — 

— ,  round,   525 
— ,   skin    of,    tumours    of,    and    their 

differentiation,  214,  215,  216,  217  — : 
Balanitis,  475  — 

Balanoposthitis,   475  — 

Banti's  disease,  314,  331  — 

Barlow's    disease,    signs   of  diagnostic 

importance,  100,  511,  656 
Base    of    skull,    fractured,    symptoms 

of,  3,   S,  6 
Bayonet   fracture,    supra-condylar,    in 

elbow-joint,  558 
Bennet's   fracture,    586 
Biceps  muscle,  hernia  of,  574 
Biliary  passages,  catarrh  of,  313 

,  injuries  of,  247,  248 

— -  — ,  obstruction  of,  321-323,  324 


Biliary  passages,  surgical  diseases  of, 

313 

,  with  peritoneal  sym- 
ptoms, 265,  273 

Bites  of  mucous  membrane  of  cheeks, 
ulcers  due  to,  qq 

Bladder,  calculi,  461 

,   aseptic,  461 

— .  — ,  cystoscopy  in,  462 

,   diagnosis  from  tumours  of,  462 

,  from  stone  in  kidney,  462 

,  in   diverticula,   463 

,  infected,    463 

,  in  skiagram,  463 

,  obstructing  urethra,  430 

,  primarj-  and  secondary,  463 

,  symptoms  of,  461 

— ,   catarrh  of,  464,  465 

— ,  colic  of,  436 

—  disturbances  in  spinal  injuries, 
492 

— ,  ectopia  of  (vesical),  370- 

— ,  examination  of,  438 

— ■  — ,   with  cystoscope,  440 

— ,  fibroma  of,  467 

— ,  fistulse  of,  427 

— ,  foreign  bodies  in,  465 

— ,  gunshot  wound  of,  252 

— ,  haemorrhage  from.,  436,  467 

— ,  hernia  of,  391 

— ,  inflammation  of,   429,   464 
injuries  of,  250,  465 

— ,  papilloma  of,  467 

— ,   rupture,   extra-peritoneal,  250 

— ■  — ,  intra-peritoneal,    251 

,  difference  between  extra- 
peritoneal and  intra-peritoneal, 
251 

— ,   sarcoma  of,  467 

— ,  tenesmus  of,  432,  458,  462 

— ,  tuberculosis  of,  459,  460,  465 

— ,  tumours  in  muscle  of,  467 

— ■  — ,  mucous  membrane  of,  466 

Blindness,  unilateral  and  bilateral, 
focal  diagnosis,  38,  39 

Blood,  condition  of,  in  Graves's 
disease,   145 

— •    cysts,  in  long  bones,  660 

— ,  effusion  of,  diagnostic  importance 
in  fractured  ribs,    189 

skull,  3,  4 

— ,  freezing  point  in  kidney  disease, 
441 


INDEX 


745 


Blood  in  joints,  680,  681,  686 

—  tumours  at  side  of  neck,   162 
— ,  vomiting  of,  hysterical,  2q6 

,  in  cancer  of  stomach,  310 

Bone,    abscess    of,    chronic,    at    lower 

end  of  tibia,  704,  705 
,  with    sequestrum,    in    humerus, 

575 
— ,  aneurism  of,  in  femur,  660 
— ,  cysts  of,  in  leg,  6gQ,  700 
— ,  perineal      fistulse,      in      connection 

with,   424 
— ,  tumours   of,   in   ileo-sacral   region, 

480 
— •  — ,   in   thorax,  218 
Botriomycosis  of  hand,  600 
Brain,  abscess  of,   17,   18,   ig 

,  diagnosis,    17,    18 

— ■  — ,  etiology,  ig,  20 

■    in    temporal    lobe    after    aural 

suppuration,  30,  31 

,  symptoms,   ig,  20 

— ,  angioma   of,    50 

— ,  base  of,  nerves  of,  44 

— ,  concussion  of,  8,  g 

,  course,  g 

,   diagnosis,  8,  g 

,  symptoms,   g,    10 

— •  — •  — ,  local,  14 

— ,  contusion  of,  7,   10,  11 

— -  — ,  diagnosis,   10,  11 

,  symptoms,  10,  11 

— ,  cortical  areas  of,  42,  43 
— ,  cysts  of,  ig,  21,  22 
— ,   focal  diagnosis,  38 

— ■ ,  in  tumours,   23,   24 

— ,  gumma  of,  18,  22 

— ,  hernia  of,   51,   52 

— •  — ,  differential  diagnosis,  53 

,  position  of,   51,   52 

,   symptoms  of,  52 

— ,  injuries  of,    17 
— ,  tubercle  of,  18,  22 
— -,  tumours  of,   17 

,   diagnosis,   18 

,   localization,  23,  24 

,  new    growths    and    granulation 

tumours,  22 
,  diagnosis       from      abscess      of 

brain,    17,    18 

—  pressure,  7,  8,   12 

,  general  and  local,  12 

,  commencing   and   complete,    13 


Brain      pressure,      commencing,      dia- 
gnosis,  14 
— ■  — ,   symptoms,  classical,   13,   14 
— ■  — ■  — ,   local,  14 
Branchial  cleft  cancer,   171 
— •  — •  fistula,   138,   i3g 

—  —  cysts,    15s,   164 

— ■  — •  — ,  diagnosis  of,   165 

Breast,  see  also  Mamma 

— ,  bleeding,  233 

— ,  cancer  of,  diagnosis,  228 

,  adhesioiis    to    pectoral    muscles- 

in,  22g 

,  contracting,   227,  22g,   232 

,   diminution    of    the    areola    in 

22g 
— ■  — ,  elevation  of  nijDple  in,   22g 
— •  — ,  enlargement  of  axillary  glands- 

in,  22g 
,  medullary,  231 

—  — )  prognosis,  231,  232 

—  — ,  retraction  of  nipples  in,  22g 
,   scirrhus,   225,   226 

— -  — ,   secondary  growths,   231 

,  ulcerating,  228,  230 

Bronchial     glands,     enlargement      of, 

200,  201 
Bronchiectasis,    diagnosis,    ig8 

—  — ,  from  abscess  of  lung  and  tuber- 

cular cavity,   ig6 

—  diffuse,  of  right  upper  lobe  of 
lung,  206 

Bronchocele,   141 

Bronchoscopy,  diagnostic  importance 
of,   1 10,   118  .       .    ' 

Brown-Sequard's  lesion,  4g4,  508 

Bryant's  triangle,  determination  of,  in 
injuries  of  hip,  612,  632 

Bulbar  palsy,  dysphagia  in,   122 

Buphthalmos  diagnosis  from  exoph- 
thalmos, 4g 

Burrowing  abscess,  due  to  spinal 
caries,  383,  386,  3g3,  515,  518,. 
519,  651 

— •  — )  gluteal,  5ig 

,  inguinal,     374,     384,     386,     3g2,. 

516,  5t7 

— -  — ,  perineal,  5ig 

^    in  iliac  fossa,  518 

loin,  375,   517 

— neck,  diagnosis  from  aneur- 
ism,  163 

— ■  — •  — •  true  pelvis,  47g 

Bursa,  iliac,  effusion  into,  652 


746 


INDEX 


Bursa,  mucous,  of  hand,  inflammation 

of,  605 
— ■  — •    foot,  inflammation  of,  727 
•    knee,      inflammation     of,      677, 

687,  688 

—  —    shoulder,   inflammation   of,    550 

—  pre-patellar,  tuberculosis  of,  687 
Bursitis,  infra-patellar,  687 

— •    over  olecranon,  570,  572 

tendo  Achillis,  726 

— ,  pre-patellar,  687,  688 

,  phlegmonous,  677 

— ,  pre-tibial,  687 
— ,  sub-calcaneal,  727 
— ,  traumatic       and       tubercular       of 
shoulder-joint,   547,  550 

—  under  callosities  of  palm,  605 


Cadre  colique,  358 

Csecal  region,  herniae  in,  as  causes  of 
intestinal  obstruction,  366 

Csecum,  movable,  344,  345 

Calcanalgia,  727 

Calcaneus,  compression  fractures,  718, 
719 

— ,  crush  fractures,  71Q 

— ,  fractures,  716,  717,  718,  719,  720 

— ,  laceration    fractures,    717 

— ,  sarcoma  of,   726,  739 

— ,  tubercle  of,  726,  728 

Cancerous  cachexia,  diagnostic  sig- 
nificance of,  306 

Cancroid  of  back  of  hand,  601 

—  concha  of  ear,  72 

—  lips,  65 

—  nose,  70 

Caput  obstipum,   185 

,  congenital,  184 

Carbuncle  of  back  of  neck,  133 
Carcinoma,  branchiogenous,   171 

—  of  bladder,  467 

—  breast,  225,  227,  228 

,  contracting,   227,   229 

,  ulcerating,  228,  230 

cervical  glands,  secondary,  159 

—  cheek,  67,  68,  69 

—  clavicle,  212 

—  concha  of  ear,  72 

—  floor  of  mouth,  99 

— ,  perforation  of,   139 

—  hand,  601 


Carcinoma    of    intestine,    351,    352 

—  kidneys,      causing     intestinal     ob- 

struction,   353 

—  larj-nx,    iiy 

,  histology,   120 

,  perforation,    139 

—  — ,  position,    120 

—  lips,  64,  67,  68 

—  liver,  325,  326 
,  secondary',  207 

—  Inng,   207 

—  nose,  67,  6q,  70 

— ■    oesophagus,   127,  130 

—  ovary,   232 

—  pancreas,  329 

—  parotid  gland,   169 

—  penis,   477 

—  pharyngeal  wall,   103 
■  — ,  perforation  of,   139 

—  prostate,   470 

—  puncta  of  eye.  69 

—  pylorus,  311 

—  rectum,  275,  352,  407,  408,  411 
— ■    scalp,     seborrhoeic,     58 

—  scrotum,  415 

—  sigmoid  flexure,  352 
— '     soft  palate,   103 

—  stomach,  305 

,   cardiac   end  of,   306 

— •  — ,  body  of,   310 

—  submaxillary  gland,   169 

—  testicle,  422 

—  thyroid  gland,   153 

•  — ,   secondary   deposits,   155 

—  tongue,   108,   109 

—  tonsillar  region,   loi,  161 

—  umbilicus,   374 

—  upper  jaw,  82,  83,  84 

—  uterus,  353 

Caries  of  spine.     See  Spinal  caries 

Carotid  gland,  new  growth  of,  172 

Carjoo  -  metacarpo  -  phalangeal  joint, 
dislocation,  585 

Cartilage,  detachment  of,  in  knee- 
joint,  670 

Cartilaginous  tumours  in  pelvic  joints, 
480 

Catheterization  of  urinary  passages, 
438,  439 

in  ruptured  bladder,  sym- 
ptoms,  250 

•  — ,  injuries  through,  472 


INDEX 


747 


Cauda  equina,  compression   of,   irrita 

tive   symptoms,    508 
Cavernitis,  chronic,  of  penis,  475  — 

Cellular      tissue,      subcutaneous,      of      — • 

finger,   inflammation  of,   603  — 

Cephalhaematoma,  3 

Cephalo-hydrocele,  traumatic,   22  — 

Cerebellar  abscess  after  chronic  otitis, 

diagnosis  of,  32  — 

—  tumours,  24  — 
Cerebello-pontine   angle,   tumours   of, 

24  — 

Cerebral  injuries,  i,  7 

— ■  — ,  pressure   symptoms,    12,    13  — 
,  symptoms,   8,   9                           •         — 

—  localization,  38  — 
,  auditory     nerve      disturbances, 

45,  46  — 

,  disturbances        of        peripheral      — 

ocular  muscles,  39  — 

,   facial  nerve  lesions,  41,  42,   43      — 

,  methods  of  marking  most  im- 
portant motor  centres  on  surface 
of  skull,  43,  47,  48 

— ,  new  growths  in  brain,  22,  23 

— ,  paralysis  of  limbs,  44 

— ,  speech  disturbances,  46,  47 

-— ,  visual  disturbances,  38 

— -    pressure,  9 

—  puncture,  diagnostic  value  in  brain 
tumours,   25 

— ■    swelling,  traumatic,   14 
Cerebro-spinal     fluid,     discharge     of, 

from  ear  and  nose  in  fractures  of 

base  of  skull,  4 
Cervical    cord,    injuries    of,    diagnosis 

of  segment,  497 

—  fistulae,    136 

— •  — ,  arising  from  a  goitre,  139 
,  cancer,    139 

—  — ,  branchial-cleft  sinuses,   138 
,  complete   and   incomplete,    138, 

139 

,  congenital,   138 

— •  — ,  median,  138 

—  — ,  mouth,    larynx,    and    pharynx, 

139 
,  origin,     course,     and     external 

appearance,  136 

3  position,   138 

,  secretion,   137 

—    ribs,  140,  163,  172 

,  symptoms  of,   172,  173 


Cervical    spine,    injuries    of,     disturb- 
ances of  motion  in,  495 

,   sensation,  497 

,  irritative  symptoms,  497 

—  veins,     dilatation     in     mediastinal 
tumours,  200 

—  vertebrae,   caries  of,    184,   514,   515, 
516 

,  contusions,   177 

,  dislocation    fracture    (complete 

dislocation),  176,  177,  178,  183 
,  unilateral  (rotation-dislocation), 

180,  182,   183 

,  fracture  of  axis,   179 

,  injuries,   176 

,  normal    position    of    atlas    and 

axis,  179 

,  osteo-myelitis  of,  180 

,   sprains,   177 

,  tubercle  of,  134,  136,  515,  516 

—  — ,  tumours  of,   181 
Cervico-dorsal    scoliosis,    with    eleva- 
tion of  shoulder,  525 

Chancre,  hard  and  soft,  476 
— ,  on  the  fingers,  60& 
— ,  primary,   on  face,   72 

,  fingers,  606 

,  gums,    100 

,  lip,  64,   98 

,  tongue,   107 

tonsillar  region,    102 

Cheeks,  bites  of,  99 

— ,  gangrene   of,   91 

— ,  lupus  of,  71,  72 

— ,  molluscum   contagiosum  of,   71 

— ,   rodent  ulcer  of,  68,  69,  70 

— ,  tumours  of,  71 

,  mucous  membrane  of,  92,  99 

Cheyne-Stokes's   respiration,   in  brain- 
pressure,   12,  13 
Chimney   sweep's    cancer   of    scrotum, 

41S 
Cholangitis,  acute,  324 

Cholecystitis,  acute,   316 

,   differential  diagnosis,  299,  316, 

317 
— ,  gangrenous,  318 
Cholesteatoma      of      temporal      bone, 

diagnosis,  26,  31 
Chondritis  of  ribs,  213 
Chondroma  of  arm,  576 
— •    cervical  rib,  173 

—  hand,  600 


748 


INDEX 


Chondroma   of   lower  jaw,   87 
— •    mamma,  234 

—  parotid  gland,    169 

—  spine,    517 

—  thigh,  659 

—  thorax,   207,   218 

—  tibia,   700 

—  toes,  738 

Chopart's  joint,  dislocation  of,  721 

,  inflammation  of,  724 

Cicatricial  stenosis  of  bowel,  352 

—  -^    pharynx,    123 
— •  — ■     stomach,  299 

Circumflex  nerve,  paralysis  of,  raising 

of  arm  in,  594 
,  through         dislocation        of 

shoulder,   549 
Cirrhosis  of  liver,  hypertrophic,  314 
— ■    stomach,  311 
Clavicle,  carcinoma  of,  212 
— ,  dislocation  of,  534,   535,   537 
— ,  fracture  of,  534,  535,  536 
— ,  osteo-myelitis  of,  210 
— ,  sarcoma  of,  212 
Club  foot,  734,  735 
,  bilateral,  with  flaccid  paralysis, 

735 
■  — /  spastic,    735 

—  hand,  595,  597 

Cochlear  nerve,  focal  symptoms  in 
injury  of,  45 

Colic,   intestinal,   347 

,  in   obstruction,  360 

Colitis,  339 

— -,  chronic  ulcerative,  341 

— ,  muco-membranous  (symptoms  and 
diagnosis),   342,   343 

Colloid  goitre,  diffuse,  142,  148 

,  unilateral,    145 

Colon,  see  Large  intestine 

Comminution  fracture  of  head  of 
humerus,   542 

lower  end  of  ulna,  581 

'OS  calcis,  719 

patella,  672 

Common  bile-duct,  closure  of,  321, 
324 

— '     by  stones,  321,  322 

tumour,  321,  322 

metastases  in,  322 

Compression  fractures,  cause  of  curva- 
ture, 523 

,  diagnosis  from  lumbago,  488 


Compression    fractures    of    os    calcis, 
717,  719 

scaphoid,  721 

spinal  column,   502,   503,   505 

— ■    brain,  9 

Concretions  in  stomach,   293 

—  umbilicus,  378 

—  urine,   436 

Concussion  of  brain,  7,  8,  9 
Condyles  of   femur,   fractures  of,   673, 

676 
—    humerus,    fractures    of,    559,    560, 

561,  562,  563,  556-565 
Condylomata,  tip  of  penis,  477 
Conglomerate  goitre,  145 
Conjunctiva,  chancre  of,  72 
Constipation,  causes  of,  343,  345 
—,  ascending  type,  343 
— ,  painful,  343,  409 
Contracture,   Dupuytren's,    597,    598 

,  of  foot,   TZ^) 

-—    in  ulnar  paralysis,  598 

— ,  posture  of  spinal  column,  531 

Contrecoup  contusion  of  brain,  15 

—  fractures  of  skull,  6,  15 
Contusion,    axial,    of    spinal    column, 

506 

—  -,  fracture    of    sernilunar    bone,    585, 

586 
— ,  intramuscular  osteoma  after,   574 

—  of  ankle,   706 

—  brain,  7,  10,  11 

—  — ,   diagnosis,   11 

-—    cervical  vertebrae,   177,   178 

—  gastro-intestinal  canal,  245 
— • •  — ,   symptoms,   246 

—  hip-joint,   621 

—  knee-joint,  668 
— ■    scrotum,  414 

—  shoulder-joint,    535,    546 

—  thorax,   189,   190 

--    urethra,    Avithout    external    wound, 

472 
Coronoid  process  of  ulna,  fracture  of, 

556,  561,  566,  567 
Coxa  vara,  631,  639-643 
,  diagnosis  between   spontaneous 

and  traumatic  forms,  627 

,  diagnosis  from  hip  disease,  642 

,  from   congenital    dislocation   of 

hip,  631,  642 

—  — ,   due    to    rickets,    636,    638,    640, 

641 


INDEX 


749 


Coxa  vara,  due  to  injury,  621, 
627 

,  false,  640 

— ■  — ,  important  diagnostic  signs,  642 

of  adolescence,  640,  642,  643 

,  unilateral,  limping  in,  641 

Cranial  nerves,  injury  of,  4,  5 

—  — •  — ,  focal  symptoms,  38-47 
Craniometry,   after  Kocher  and  Kron- 

lein,  47,  48,  49 

,   diagrams  of,  47,  48 

Cretinism,  fractures  in,  670,  673 

Crutch-palsy,  594 

Cubitus  valgus,  561 

Curvature  of  spine,  522-533 

Cyroscopy,  441 

Cystadenoma  phyllodes  of  the  breast^ 

232 
Cystic  goitre,   146,   148 
Cystitis,  433,  465 
— ,  causes  of,  464 

— ,  composition  of  urine  in,  434,  465 
— ,  primary,  diagnosis  of,  464 
— ,  tubercular,  465 
Cystoma  of  jav\-,  multilocular,  87 
— ■    testicle,  422 
Cysto-sarcoma  phyllodes  of  the  breast, 

232 
Cystoscopy,    427,    440,    441,    456,    459, 

462,  464 
Cysts  between  testicle  and  epididymis, 

420 
--,  blood,    162 

—  in  true  pelvis,  407 
— ,  lymph,   161 

—  of  abdominal  cavity,  diagnosis 
from  sacculated  tubercular  effu- 
sions, 285,  290 

—  bones  of  leg,  699,  700 

—  brain,  traumatic,    17,   20 

—  branchial  clefts,    155 
—    breast,  223,  224,  225 

—  -    hand,  traumatic,   599 

—  jaw,  84,  87 

—  kidneys,    congenital,   458 

—  liver,   326 
,  parasitic,  327 

—  mouth  cavity,  92,  93 

— •    neck,  congenital,   155,   164 

—  pancreas,  329 

—  prostate  and  retro-prostatic  tissue, 
481 

—  spleen,  331 


Cysts  of  thyreo-glossal  duct,   155 

—  thyroid,  148 

—  umbilicus,   373 

—  urachus,   372, 

— ■    vitelline  duct,  2>73 

D 

Dacrocystitis,  phlegmonous,  61 
Dactylitis,  syphilitic,  608,  609 
Defense      musculaire      in      abdominal 

injuries,   246,  258 
Degeneration,       fibro  -  epithelial,       of 

mamma,  223 
Dental  cysts,  83,  84,  87 

—  periostitis,  60 

—  sinus,   inflammation  of  jaw  in,   78 
Derangement,   internal,   of  knee-joint, 

670 
Dercum's   disease,    175 
Dermatitis  of  hand,  602 

,  through  drugs,  602 

Dermoid   fistulse   around    coccyx,    423, 

486 
— •    of  back  of  neck,   174 

—  face,   63 

-     floor  of   mouth,   89,   93 

—  -     lung,    207 

—  mediastinum,    207 

—  -    neck,    165 

--    pelvic  cellular  tissue,   481 

—  penis,   475 

—  -    sacral  region,  486 

—  scrotum,  415 

—  skull,  51,  53 

—  testicle,  422 

—  umbilicus,   378 
— ,   sublingual,  93 

— ,   suppurating,    89,    131 

— ,   supra-orbital,  63 

Detached  fracture  of  coronoid  process 

of  ulna,   561,   566 
— •  —    head  of  fibula,  674,  676 
internal      condyle      of      femur, 

670 

epicondyle    of    humerus,    563 

OS  calcis,  718,  719 

rim  of  acetabulum,  617 

spine  of  tibia,  671,  674 

styloid    process    of    ulna,     518, 

577,  580 

trochanter  of   femur,   622 

tuberosity  of  humerus,  542,  544 


750 


INDEX 


Dextroposition  of  stomach,  236 
Diaphragmatic    hernia,    after    injuries 

to  lung,   igi 

,  diagnosis   of,  367 

Diaphyseal    tuberculosis    of   humerus, 

576 
— ■  —    tibia,   703 
— •    tumours  of  femur,  664 
Diphtheria,  bacteriology  of,   112 
— •    of  larj-nx,   112,   113 

—  throat,   112 

— ,  paralj'sis  of  palate  in,    122 
— ,   secondary  symptoms,    113,    114 
Diplegia,    from    spinal    cord    haemor- 
rhage, 495 
Diploe,  sarcoma  of,  57 
Dislocation,     acromio-clavicular,     539, 

5  40 
— ,  axillary,   542 
— ,   central,   of  femur,  620,   630 
— ,   compression-fracture  of  spine,  505, 
S07 

—  — -of  cervical  vertebrae,  176,  505 
— ,  congenital,  of  hip,  631,  634,  635 

—  fracture,  complete,  503 
in   ankle,   715 

of  cervical  vertebrae,   177 

— •  —    spinal  column,   503 

,  typical,  inter-carpal,   585,   587 

— ,  iliac,  615,  616 

— ,  ileo-pectineal  of  pubic,  617,  618 

— ,  infra-cotj'loid,    620 

— ,  obturator,  6ig,  620 

—  of  ankle,   712,   714,   716 

—  astralagus,  715,  716 

—  carpo-metacarpo-phalangeal     ioint, 

58s 

—  Chopart's     and     Lisfranc"s     joint, 
721 

—  clavicle,    534,    536 

—  elbow,  555 

,  backwards,    554,   561-568 

,  forwards,    568 

—  ■ — ,  lateral,   562 

,  outwards,  561 

-~    femur,  615 
— ,  central,  620 

—  hip,   610,    615,   616,   617,    618,    6ig, 
620 

,  backwards,  615,  616 

—  — ,  complicated,  616,  617 

.  congenital,  631,  634,  635,  637 

,  forwards,  617 


Dislocation     of     hip,     inflammatory, 
645 

—  humerus,  538,  539,  540 

— -  inter-carpal  phalangeal  joints, 
584 

—  knee-joint,  676 

—  lower  jaw,  74 

—  lumbar  vertebrae,   500 

—  neck,  unilateral,   182,   183 
,  complete,   176,   178,   182 

—  patella,  676 

—  peroneal  tendons,  712 

—  shoulder-joint,   538,  539 

—  tibia,  676 

—  ulna,   561 

—  vertebral  column,  502,  503 
,  complete,   506 

—  wrist,  578,  579,  583,  584,  585 
— ,  perineal,   619 

— ,  radius,   563,   566 

— ,   sciatic,  615,  616,  617 

— ,   semilunar  bone,   579,   583 

■ — ,   sub-astragaloid,   716 

— ,   sub-coracoid,   539,   542 

— ,   supra-cotyloid,  620 

— •  — ,  congenital,   637 

Diverticula  in  lower  portion  of  large 
intestine,   inflammation,  276 

— ,  Meckel's,  invagination  of  intes- 
tine,  caused  by,   364 

—  of  bladder,  stones-  therein,  467 

—  oesophagus,   128,  135,   140,   162 
— ,  perforation  of,  267 

Dorsal    scoliosis,    527,    528,    529,    530, 

531 

—  spinal    cord,    local    diagnosis,    500, 

501 

—  vertebrae,      compression      fracture, 

503 

,  i^rimary   scoliosis  of,   532 

,  segmental  diagnosis  of,  500 

— -  — ,   suppuration,   516 

— ,   with  burrowing  abscess,   517 

Duodenal  ulcer,  diagnosis  from  chole- 
cystitis, 316 

■    gastric  ulcer,  297 

■    intestinal   obstruction,   358 

—  — ,  perforated,   299 
— ■  — ,  peritonitis  in,  265 
Dupuytren's  contraction,  597,  598 
Dura     mater,     haematoma     of     (local 

pressure  symptoms),   12,   13,    14 
,  pedunculated  fibroma  of,  175 


INDEX 


751 


Dysentery,    diagnosis    from    intestinal 

obstruction,    347 
,  ulcerative    colitis    in    its    later 

stages,  341 
Dyspnoea  in  cerebral  pressure,  13 

—  diphtheria,   113,   114 

— •    mediastinal   tumour,    igg 

—  perforated  gastric  ulcer,  2q8 
Dysuria,   429 


Ear,  cancroid  of,  72 

— ,  concha  of,  prominence  of,  in  mas- 
toid otitis,  27,  28 

— ,  haemorrhage  from,  diagnostic 
significance   in   fractured  base,  3 

— ,  lupus  of,  72 

Echinococcus  of  kidnej-,  465 

—  liver,  326 

,  multilocular,  326 

—  lur-g,  207 

—  mediastinum,  207 

—  spleen,  331 

—  vertebral  column,  509,  510 
Elbow  glands,  inflammation  of,   568 
— •    joint,  dislocation,  554,  555 
,  backwards,     554,     555,     556, 

557 
■  — ,  complete     and     incomplete, 

S6i 

,  forwards,   556,   557,  567 

— ,  lateral,   555,    562 

— ,  outwards,  555 

— -  —    fractures,     at     lower     end     of 

humerus,    555,    556,    557,    558,    559, 

560,   561,   562-565 
— •  — •  — ,  coronoid  process,  566 
head     of    radius,     565,     566, 

567 

olecranon,   556,   557 

ulna,  ^56,  561 

,  inflammation,   569,   571 

—  — ,  injuries  of,  553 

,  examination    for,    554 

■ by  inspection,   554 

— palpation,    560 

testing    movements,    555 

•  —    X-ray  examination,    567 

—  — ,  normal,  557 

—  — ,  position  of  three  lines  of  frac- 

ture of,  563 
,  sprain  of,  566,  567 


Elbow  joint,  syphilis  of,  571 

,  tuberculosis  of,  569,  571,   572 

Elephantiasis  of  penis,  475 

—  scrotum,   415 

Embolism  of  mesenteric  artery,  264 

—  lung,    107 
Embryoma  of  testicle,  422 

,  diagnosis         from         embryoid 

tumour,   422 

Eminentia  capitata  humeri,  abrasion 
fracture,   565 

Emissary  inastoid  vein,  thrombo- 
phlebitis of,  2>3 

Emphysema  in  injuries  of  thorax,  190 

Empyema  necessitatis,  209 

— •    of  antrum  of  jaw,  83 

—  gall-bladder,    323 

—  lung,    195,    196 

— -  — ,  scoliosis  after,  522 
Encephalocele,   52 
Encephalomeningocele,    52 
Enchondroina,   see   Chondroma 
Endothelioma,    relation    to    cutaneous 

cancer,  70 
Enteroptosis,  235,  236,  242,  243 
— ,  confirmation  by  palpation,  240 
— •  —    by  skiagram,  241 
Epicondyle      of      humerus,      internal, 

fracture  of,  558,  559 
Epicondylitis  of  humerus,  572 
Epididymitis,     gonorrhoeal,    415,     416, 

417,  419 
— ,  syphilitic,  419 
— ,  traumatic,  416 

,   sinuses  in,  420 

— ,  tubercular,  420 

Epigastrium,   acute  inflammation,   265 

— ,  chronic  abscess  of,  368,  369 

— ,  hernia  of,  369,  371 

— ,   subcutaneous  lipoma  of,  369 

Epilepsy,     diagnosis     from     hysteria, 

34,  35 
— ,   diagnostic    significance    of    course 

of  attacks,  36 

,  the  history,  35,  36 

,  physical   condition   in   inter- 
vals, 36,  2,7 
— ,  epileptiform       attacks      in      brain 

tumours,   18 
— ,  Jacksonian,  attacks  of,  in  cerebral 

pressure,  17 

cerebral   tumours,    18,   2>7 

,  typical  form  of,  36 


752 


INDEX 


Epilepsy,   surgical   significance  of  the 

various  forms,  34 
Epinephritis,   442 

Epiphyseal  swellings  of  femur,  661 
Epiphysis  of  tibia,  tuberculosis  of,  704 
—5  separation   of,    at   head   of   femur, 

627,  64s 
in  the  new-born,  and  in  infants 

with  hereditary  syphilis,   545 

radius,  579,  580 

Epispadias,   47s 

Epithelial    cysts   of   neck,    congenital, 

164 

,  traumatic,  of  hand,  599 

Epithelioma  of  face,  calcified,  64 

Epulis,  Q4 

Erb's  paralysis,  posture  of  hand  and 

fingers   in,    594 
Erysipelas  of  face,  59 

—  scalp,    51 

Erysipeloid  of  finger,  603 
Esmarch's  paralysis  in   the  upper   ex- 
tremity,  594 

Eye  muscles,  nerves  of,  injuries  to,  5 

,  peripheral      derangements     of, 

focal   diagnosis,  39-41 

,  in  Graves's  disease,  143 

Eyelids,  cancer  of,  at  puncta,  69 

— ,  ulcers  on,  70 

— ,  xanthelasma  of,  64 

Eyes,  conjugate  deviation  of,  in  cere- 
bral pressure,   13,   14 

,  diagnosis  from  peri- 
pheral derangements  of  ocular 
muscles,  39 

Exophthalmos,  diagnostic  significance 
of  unilateral  and  bilateral,  49,  50 

— •    in  Graves's  disease,  49,  143 

— ■    pulsating  exophthalmos,  50 

— ,   surgical,  49 

—  — ,  mode  of  origin,  50 
Exostosis  of  femur,  cartilaginous,  659, 

660,  661 
— ,   subungual,  of  foot,  730 
— ■    tibia,   700 

Expansile  pulsation  in  aneurism,  163 
Extension     apparatus     of     knee-joint, 

laceration  of,  671 

—  fracture  of  lower  end  of  humerus, 
5S8,   561 

Extra-uterine     pregnancy,     peritoneal 

symptoms,    273 
Extremities,      measurement      of      the 

lower,  after  injuries,  612,  613,  626 


Extremities,  mobility  of,  after  cerebral 

injuries,  44 

vertebral  injuries,  489,  490 

— ,  rigidity  of  the  lower,  causing  limp, 

611 
— ,  sciatica  and  other  painful  diseases 

of  the  lower,  689-693 
— ,  surgical   diseases  of,   536 


Face,  angioma  of,  64,  66 

cirsoid  aneurism,  64 

cutaneous  warts  of,  64 

dermoid  of,  63 
— ,   supra-orbital,   63 

epithelioma  of,  64 

erysipelas  of,  59 

inflammatory  processes  of,    59 

lipoma  of,  64 

lupus  of,  66,  68,  71 

primary  chancre  of,  72 

sebaceous  cyst  of,  63,  64 

syphilide  of,  71 

tumours  of,  62 

— ,  closed,  63,  64 

ulcerative  processes  of,  62,  64 

xanthelasma  of,  64 
Facial  nerve  injuries,   focal  diagnosis 

of,  41-43 
,   diagram  of,  41 

—  paralysis   in    fracture   of    skull,    5, 
41,  42 

,  tetanus,  75,  "]"] 

False  croup,  symptoms  of,  112 
— ■    tail  in  sacral  region,  486 
Fat  necrosis  in  pancreatitis,  264 
Fatty  neck,  Madelung's,  174 

—  tissue,  retrobulbar,   venous   throm- 
bosis of,  61 

Femoral  hernia,  392,  393-394 

,  abnormalities  in,  395 

,   diagnosis  of,  394,  395 

,   from  burrowing  abscess,  392 

distension       of       saphenous 

vein,  392 

,  glandular    enlargement,   392 

pedunculated      subserous 

lipoma,  393 
— ■  — ,  external,  395 

in  women,  393 

,  with  divided  sac,  30S 

,  pro-peritoneal,  396 

,   strangulated,  396,   403 


INDEX 


753 


Femur,  Barlow's  disease,  657 
— ,  chondroma  of,  659 
— ■    dislocation,  615 

—  — ,  anterior,  617,  618,  6iq 
,  central,  620,  630 

—  — ,  complicated,  617 

,  congenital,  631 

,  posterior,  616,  617 

— ,  exostosis,  659,  660,  661 

— ,  fracture  of  cartilage  of,  668,  669 

,  diaphysis,  628 

— • -at  upper  end,  622-630 

at   lower  end,   672,  673,   675, 

676 

,  spontaneous,   665,   666 

— ,  osteomyelitis     of,     643,     656,     657, 

659,  662,  663,  664,  665 
— ,  sarcoma  of,  657,  658,  661 
— ,  tuberculosis  of,  658,  661,  663 
Fibro-adenoma    of    mamma,    224,    226, 

232,  233 

,  phyllodes,   223,   233 

Fibro-lipoma     of     muscles     of     back, 

216 
Fibroma  of  abdominal  wall,  374,  375 
--    arm,   572 

—  back  of  neck,   175 
-'  -    bladder,  467 

---    hand,  600 

—  knee-joint,  687 
— ■    larynx,  121 

--    leg,  87 

—  -    lower  jaw,  697 

—  -    mouth  cavity,  92,  94 
-—    nail-bed  of  toes,  739 

-    naso-pharynx,   84,  85,  96,    121 

—  neck,  166,  169,  170 
--    pelvis,  480 

—  sacral  region,  486 
--    scalp,  55 

— ■    scrotum,  415 

^^    thigh,  657,  658 

-—    thorax,  216,  217,  218 

—  tongue,   105 

— -    umbilicus,  374 

Fibro-myoma  of  ligaraentum  teres,  37- 
— •    of  the  uterus,  289 
Fibro-sarcoma  of  neck,   170 

—  skin  of  back,  214 

—  small  intestine,  348 

—  tibia,  699 

Fibula,  aneurism  of,  699 
— ,  bending  of,  708,  709 


Fibula,     congenital     defect     of,     732, 

734 

— ,   fracture  of,  707,  708,  709,  710 
head  of,   detachment,  674 

Finger,  anomalies  of  posture  in  nerve 
lesions,   593,  594,  595 

— ,  bent  little,   597 

— ,  derangement  of  movement  in 
tendon-sheath   inflammation,    588 

— ,   dermatitis  of,  602 

— ,  destruction  of,  by  leprosy,'  Ray- 
naud's disease  and  syringomyelia, 
607 

— ,   Dupuytren's   contraction,    597,    598 

— ,  erysipeloid,  603 

— ,  inflammation  of,  601 

—  — ,  chronic,  605 

—  — ,  subcutaneous  cellular  tissue  of, 

603 
— ,  injuries  of,  586,  587 

—  joint,  inflammation  of,  604 
,  gonorrhoeal,  603 

,  purulent  inflammation  of  bone, 

605 
— ,   syphilis  of,  603,  608,  610 
— ,  teno-synovitis  of,  588,  590,  603 

■  — ,  crepitating,  604 

,  gonorrhoeal,  603 

— ,  trigger,  598 

— ,  tuberculosis  of,  599,  606 

— ,  tumours  of,  599 

—  — ,  innocent,  599 

,  malignant,  600,  601 

Fissures  of  fibula,  714 

—  pelvic  bones,  630 
— •    rectum,  409 

—  skull,  6,  7 
,  course  of,  6,  7 

—  upper  jaw,  73,  74 
Fistula  in  ano,  424,  425 

,  acquired,   inflammatory,  424 

;  congenital,  424 

—  in  connection  with  goitre,   139 
Flat-foot,  729,  730,  731 

— ,   contracture  in,  7:^3 

— ,  paralytic,  734 

Flexion  fracture  of  lower  end  of 
humerus,  562 

Flexor  tendons  of  fingers,  teno-syno- 
vitis of,   590 

Focal  diagnosis  in  cerebral  diseases, 
38 

Foot    angioma  of,  738,  739 


754 


INDEX 


Foot,   bursa  of,   inflammation,    726 

— ,  carcinoma  of,  739 

— ,  chondroma  of,  738 

— ,  deformities  of,  729 

— ,  dislocation  of,  712,  713,  714,  715 

— •  — ,  at     Chopart's      and      Lisfranc's 

joint,   721 

,  Volkmann's,  734 

— ,  fibroma  of,  739 

— ,   gout  of  great  toe,  728 

— ,  gumma  of,  725 

— ,  habit  contracture  of,  732,  y2>3i  73^ 

— ,  inflammation  of,  724 

metatarsus  and  toes,  728 

tarsus,  724 

— ,  injuries  of,  721-724 

— ,  lipoma  of,  739 

— ,  normal,  731 

— ,  perforating  ulcer  of,  739 

— ,  peri-articular  abscess  of,  724 

— ,  sarcoma  of,  726,  739,  740 

— ,  syphilis  of,  725,  740 

— ,  tuberculosis  of,  725,  726,  740 

— ,  tumour  of,  722 

— ,  ulcers  of,  738,  739 

Foreign  bodies  in  bladder,  438 

knee-joint,  669,  678 

— ■  — •  larynx,   114,   116,   117,   118 

■  — ,  dyspnoea  in,  118 

oesophagus,  123,   126 

— -  — •  pharynx,   123,   124 

— ■  — •  rectum,  411,  412 

— ■  — ■  stomach,  293 

trachea     and     lungs,     116,     117, 

196 

urethra,  430 

Fork-like  posture  of  hand  in  fracture 

of  radius,  577 
Foveola  coccygea,  423 
Fracture  at  ankle-joint,  706,  710 
— ■    knee-joint,  672-676 
— ,  Bennet's,  586 
- -,  bi-malleolar,  710,  713,  715 
— ,  diacondylar  at  knee-joint,  675 
— ,  greenstick,  534,  577 

—  of    anatomical    neck    of    humerus, 

541,   544 

—  astragalus,  711 

—  axis,    179 

—  capitulum  radii,  565,  567 

—  clavicle,   534,   535 

—  condyles  of  femur,  673,  676 


Fracture  at  coronoid  process  of  ulna^ 

556,   561,   566,   567 
— •    epi-condyles  of  humerus,  556,  559, 

562,  563,  568 

—  femur,  at  lower  end,  672,  673,  675, 

676 
— ■    femur,    at    upper    end,    610,    614, 

618,    621,    623,    624,    627,    628,    631 

,   shaft  of,  628 

,  spontaneous,  665,  666 

—  fibula,  674,  708,  709,  711 

—  humerus  at  lower  end,  562-568 
at  upper  end,  540,  541,  543,  54S, 

546 

below  tuberosities,  541,  543,  544 

,  condyles  of,  556,  559,  560,  561, 

562,  563,  564 
,  diacondylar,  556,  560,  561,  567, 

569 

through    tuberosities,     540,    541, 

542,  543,  544,  545 

—  laryngeal  cartilage,  116 

—  leg,  672,  673,  676,  707 

—  lower  jaw,  72> 

—  malleoli,    706,    707,    708,    709,    710, 

713,  715 

—  metacarpal  bones,   586 

—  metatarsal  bones,  722,  723 

—  neck  of  femur,  625 

,  inter-trochanteric,    623,    624,. 

625,  628,  631 
,  per-trochanteric,     623,     625,. 

629,  631 
,  subcapital,     622,     623,     625,. 

628 
,   subtrochanteric,      623,      624^ 

625,  629,  630 
— -    neck  of  scapula,  545,  546 

—  olecranon,   556,   557 

—  OS  calcis,  716,  717,  718,  719 

—  patella,  672,  674 

— •  pelvic  fossa,  628,  62Q 

—  pelvic  ring,  628,  629 
— ■  pelvis,  474,  629 

—  radius,     565,     566,    577,     578,     579^ 

580,  581,  582 
— ■    ribs,  187 

—  rotula,  556,  559 

—  scaphoid  of  wrist,  584,  587 
of  foot,  721 

—  scapula,  545,  546 

—  semilunar  bone,  585,  586 


INDEX 


755 


Fracture    of    sesamoid    bone    of    foot, 

723,  724 
— -    skull,  I 
— ■  — ,  course  of,  6 
,  secondary  injuries,   5 

—  sternum,   188 

—  sustentaculum  tali,  719 

—  tibia,  673,   676 

,  at    lower    end,    706,     707,    708, 

709,  710,  711,  714 
,  infracondylar,  673,  676 

—  tuberosity  of  fifth  metatarsal,   723, 

724 

—  upper  jaw,  jz,  74 

—  vertebral    column,     176,     177,    488, 

502,  503,  504,  50s 
— ,  Shepherd's,  711 
— ,  supracondylar,    at    lower    end     of 

humerus,    556,    557,    558,    559,    561, 

568 

,  knee-joint,  672,  673,  676 

— ,  supramalleolar,  713 
Furuncle  in  axilla,  211 
— ■    of  back  of  neck,   133 

—  lips,  59,  89 


Gall-BLAUDER,  abnormalities  of  posi- 
tion, 316,  317 

— ■  — ,  empyema  of,  323 

■ — ■  — .  — ,  source  of  infection  for  cere- 
bral abscess,  20 

— -  — •    fistulae,  378 

—  — ,  gangrene  of,  318 
,  hydrops  of,  323 

•  — ,   diagnosis        from        floating 

kidney,  323 

— •  — ,  rupture  of,  248 

Gall-stone  colic,  314 

•  — ,  anatomical  basis  of,  315 

,  diagnosis      from      epigastric 

hernia,   315 

— from  peritonitis,   262 

— ■ -■  renal  colic,  315 

— -  stones  causing  intestinal  obstruc- 
tion, 321,  362 

,  diagnosis    of,    314,    318,    319 

,  in  small  intestine,  275 

Ganglion  of  wrist,  600 

Gangrene  of  foot,  diagnosis  from 
sciatica,   691 

—  lung,  195,  196 
— ,  senile,  691 

49 


Gangrene  of  toes,  728 
Gastro-intestinal    canal,    contusion  of. 

245 

• ,   diagnosis,  246 

,  gunshot  wounds  of,  252,  253 

•  — ,  rupture    and    its    symptoms, 

245,  246 
Gastroptosis,  238,  241,  242 
Genitalia,     diseases     of,     in     women, 

examination  for,  439 

—  of  hermaphrodite  with  vagina  and 
testicles  in  hernial  sac,  383 

Glanders,  ulcers  of  nose  in,   103 
Glandular  abscesses  in  neck,  132,  134, 

135 

,  chronic,   135 

— ■    swelling  in  cancer  of  breast,  229 

— •  — ■    inguinal  region,  657 

• ,  diagnosis     from     hernia, 

392 

in  leukaemia  and  pseudo- 
leukaemia,    157 

supra-clavicular  fossa  in  cancer 

of  stomach,  309 

syphilis,  156 

tonsillar  ulceration,  loi,  102 

tuberculosis,   156,   157 

■    of  neck,  155,   156 

— •  — •  — ,  malignant,    159 

Glossitis,  symptoms  of,  90 

Glottis,  oedema  of,   114 

Goitre,   aberrant,   96 

— ,  abnormalities  in  position  of,   149 

— ,  circumscribed   nodular,    146,    148 

— ,  complication  of,   150 

— ,  cystic,  146,  147,  148 

— ,  deep,    149 

— •  — ,  diagnosis  from  mediastinal 
tumour,  201 

— ,   diagnosis  from  aneurism,   163 

- — ,  diffuse  colloid,  142 

— ,  external  appearances  of,  142 

— ,  haemorrhage  in,  148,  150 

— ,  heart,  thyreotoxic,  144 

— ,  inflamed,  151,  152 

■,  oesophageal  stenosis  in,  127 

—  in  Graves's  disease,    143,   144 

— ,  intra-thoracic,  149,  200,  202,  205 
— ,  malignant,    153,    154 

,  diagnostic  signs  of,    153 

— ,  pendulous,  145,  148 
— ,  plongeant,  147,  148 
— ,  proliferating   (Langhans'),    154 


756 


INDEX 


Goitre,  retro-sternal,   149 

-— ,  retro-tracheal,   149,   150 

--,  retro-visceral,   149 

--,   secondary  growths,   57,   155 

— ,  skiagram  of,   148,   149 

— ,  vascular,  142 

Gonorrhoea,     diagnosis    from    sciatica, 

689 
--,  examination  of  urine  in,  433 

—  of  ankle,   725 
— •    epididymis,  416 

—  finger-joints,   605,   606 

—  hip- joint,  644 

—  knee-joint,  678 

—  pelvis  of  kidney,  451 

—  penis,  477 

—  prostate,  471 

—  rectum,  408,  411 

—  shoulder-joint,   551 

—  tendon  sheaths  of  hand,  603 

—  urinary  passages,  433,  434 

—  wrist,   589 
Gout,  728 

—  of  foot,  728 

—  hand,  605 

■Granulation  of  dorsal  spinal  cord,  508 
— ,  tubercular,  of  hand,  599 
'Granulomata,   inflammatory   of   brain, 

diagnosis,   22 

— ,  local,  23,  24 

■Graves's    disease,    blood    condition    in, 

145,  146 
,  changes  of  thymus  in,    146 

—  — ,  commencing,    143 

,  diagnostic  signs  of,  49,   143-146 

,  forme  fruste,  144 

,  pronounced,     144 

Groin,     bilocular     or     communicating 

hydrocele  in,  374,  387 
- — ,  burrowing  abscess,  374,  375 
— ,  glandular  enlargement  in,  382 
— ,  lymphadenoma,  375 
— ,  sarcoma  of,  375 
— ,  sinuses  in,  378 
— ,  strangulation  of  testicles  in,  399 
— ,  testicles  in,  374,  383 
— ,  tubercular,  375 
— ,  tumours  of,  ^-/z,  375 
•Gumma  of  arm,  571,  574,  575 

—  brain,   18,  22 
-—    foot,  725 

—  knee-joint,  691 
- —    larynx,  120 


Gumma  of  leg,  701 

—  liver,  326 

—  mamma,  222 

—  mouth  cavity,   100,   loi.    102 

—  neck,   136,   140 

—  palate,  95,    103,    105 

—  penis,  477 

—  pharyngeal  wall,   103 

causing  paralysis,   123 

— ■  ribs,  213 

—  shoulder,   553 

—  skull,  56,   58 

— -  spinal  cord,  510 

— •  sternum,  213 

—  testicle,  419 

—  thigh,  658 

—  thoracic  wall,  211 

—  tongue,   106,   107 

—  tonsillar  region,   loi 
— -  vertebrae,  521 

Gums,  acute  circumscribed,  and  wide- 
spread  swelling  of,  89 

— ,  growths  of,  94 

— ,  haemorrhage  from,  100 

— ,  lead  line   on,   100,   262 

— ,  pus   from,    100 

— ,  tubercular,  79 

— ,  ulcers  of,   100,   108 

H 

Habit  contracture  of  foot,  '/■Z2>,  73^ 
Haematocele  of  testis,  416,  420 
— ,   retro-uterine,  274 
Haematoma,  extradural,  12,  16 
— ,   intradural,  12,   16 

—  in  vicinity  of  Broca's  convolution, 

14 

—  of  ear,  64,  65 

— •    spinal  cord,  494 
— ,  peri-tubal,  271,  274 
— ,  peri-urethral,  474 
Haematomyelia,  symptoms  of  paralysis 

in,  494 
Haematuria  in  renal  calculi,  454 

—  — •    tumours,  456 

—  urinary  tuberculosis,  460 
Haemophilia,  effusion  in  knee-joint  in, 

682,  686 
— ,  haemorrhages  of  gums  in,   100 
— ,  renal  haemorrhages  in,  436 
Haemorrhoids,  409,  410 
Hair  tumour  in  stomach,  293 


INDEX 


757 


Hairy     margin     of     head     and     face, 

tumours  of,  71 
Hallux  valgus,   728,   736,  -/Zl 
Hammer-toe,  736,  737 
Hand,  abnormal  postures  of,  592 
in    fracture    of    radius,     577, 

578 

nerve  paralj'sis,   592-595 

,  position  of  damage,  593 

— ,  angioma,  600 

— ,  botriomycosis  of,  600 

— ,  carcinoma  of,  601 

— ,  chondroma  of,  600 

— ,   deformity  of  Madelung"s,   596,   597 

— ,   dermatitis  of,  601 

— ,  epithelial  cysts  of,  traumatic,  599 

— ,  fibroma  of,  600 

— J  ganglion  of,  599 

— ,  gout  of,  605 

— ,  inflammation  of,  acute,  601,  605 

bursae  under  callosities,  605 

bone,  608 

,  chronic,  605 

skin,  605 

tendon  sheaths,  607 

— ,  injuries  of,  576,  605 

— ,  leprosy  of,  606 

— ,  lipoma  of,  599,  608 

— ,  lupus  of,  606 

— ,  cedema  of  dorsum  of,  586,  588,  605 

— ,  osteomyelitis  of,  605 

— ,   -post-morte^n  tubercle  of,  606 

— ,  sarcoma  of,  600 

— ,  sebaceous  cyst  of,  599 

— ,   syphilis  of,  608 

— ,  tendon    sheath,    inflammation    of, 

588,  602 

— •  — ,  gonorrhoeal,  608 

■  — J  tubercular,  589,  607 

— ,  tubercle  of,  599 

■    bone,  608 

— ,  tumours  of,  599 

— ■  — ,   innocent,  599 

— ■  — ,  malignant,  600 

Head,  abnormal  posture  of,  175 

,  asymmetrical,  181 

,  symmetrical,   176,    184 

— ,  rigidity  of,  painful,   175 

of  gradual  onset,   181 

— •  — -of  sudden  onset,   176 
— ,  surgical  diseases  of,  i 
—    tetanus,  75 


Head,    tetanus,    with    facial    paralysis, 

111  76,  TJ 
— •    tumours  acquired,  55 

,  innocent,  55 

■  — ,  malignant,  56-58 

,  congenital,  51 

Heart,     compression     of,     by     effused 

blood,   193 
— ,  injuries  of,  191 

5  avoidance  of  probing  in,   191 

,  cardiac  dulness  in,  192 

,  diagnosis,   194 

,  pure,  192 

—  — ,  subjective  sensations  in,    192 
— ■  — ,  with  injury  to  pleura,   193 
•  — 3  position    and    nature    of, 

191 

,  reflex  symptoms  in,   192 

Hemianopia,     diagnostic     significance 

of,  in  cortical  tumours,  23 
Hemianopsia,    diagnostic    significance 

in  brain  jjressure,   14 
— ,  focal  diagnosis  of,  38,  39,  40 
Hernia,  abdominal,  376 
— ,  crural,  392,  393,  394,  395 
— ,   duodeno-jejunal,   366 
— ,  epigastric,  370,  371 
,   diagnosis     from     biliary     colic, 

314 
— ,  Hesselbach's,   396 

—  in  csecal  region,  366 

— ,   incarcerated,   365,   398,   400 
— ,   inguinal,   374 

,  external,  379,  386 

,  internal   (direct),  390 

—  in     linea     semicircularis      Spigelii, 

376 
— ,   intermuscular,  380,  381,  385,  386 
— ,  internal,  in  csecal  region,  366 
— ■    in  Winslow's  foramen,  366 
— ,  irreducible,  398 
— ,  labial,  382,  387,  388 
— ,  Littre's,  401 
— ,  lumbar,  375 
— ,  multilocular,  372 
— ,  obturator,  365 

—  of  diaphragm,   igi,  367 

—  umbilical  cord,  ziZ 

— ,  pro-peritoneal,  381,  384,  396 
— ,  scrotal,  387,  388 
— ,  strangulated,       irreducibility      of, 
398 


758 


INDEX 


Hernia,  strangulated,  condition  found 

at  operation,  403,  404 
— ,  strangulated,  398-406 

—  — ,  after   reduction,   353,    366,   405, 

406 
— .  — .  — .  — ,  diagnosis    from    a    stran- 
gulated inguinal  testicle,  400 

— . ■  —     hydrocele,   3q8 

— ■    peritonitis,  263 

diagnosis  of,  310,  3Q8,  399 

— .  — ,  fistulse  subsequent  to,  370 

_  — ,  its  position  in  femoral   lierniEe, 

396,  403 

—  -^  — ■  —    in   inguinal   hernise,   403 

in  umbilical  herniae,  403 

,  intestinal  obstruction  with,  366, 

402 
— -  — ,  reduction  en   masse,  402,   406 

,   stages   of,   404 

— ,  subcutaneous,  381,  384,  386 

— ,  tendency  to,  379,  381 

— ,  traumatic,   396,   397 

— ,  umbilical,  371,  372 

Hernial  sac,  appendicitis  in,  401 

— •  — ,  contents  of,   402 

in       male       hermaphrodite, 

383 

—  — ,  peritonitis  of,  401 
,   sub-divided,   384 

—  — ,  tuberculosis   of,   401 

with  peri-hernial  fat,  389 

Hip,  adducted  (coxa  adducta),  639,  640 
,         important      diagnostic 

symptoms,  641 
— ■    disease,  643 
— -  — ,  acute  infective,  643,  644,  646 

— • ,  consequences  of,  645 

,  chronic,     non-tubercular,     654, 

655 
,   diagnosis    of,    differential,    650, 

6si 

—  — •  — ■  by  gait,  646 

painfulness,  650 

•  —  palpation  of  joint,  650 

posture  of  leg,  649 

skiagram,    653 

— ■ testing  movements  of  joint, 

647,  648 

,   secondary  changes  in,   653 

,  tubercular,    646,    647,    648,    649, 

650,  653 
,     variety  and  degree  of,  652 

—  joint,  acute  inflammation  of,  643 


Hip-joint,   acute  inflammation   of,   re- 
sults, 645 
,  arthritis  deformans  of,  639,  64'^, 

6SS 
—  — ,  chronic  inflammation  of,  646 
— ■  — ,  contusion  of,  621 
— ■  — ■  — ,   diagnosis,  614 
,   deformities  of,  congenital,  631- 

639 

,  non-traumatic,    631 

— -  — ,  dislocation  of,  615-620 

,  anterior,  617,  618,  619 

— ,  complications,  616,  617 

,  congenital,     631,     634,     635, 

637,  639,  651 

,  inflammatory,  649 

— ,  irregular,  616 

,  posterior,  615,  616,  617 

,  examination  of,  611 

by  inspection,  611 

palpation,   614 

testing  mobility,  614 

fracture  of,  610,  621-627 

gonorrhoea  of,  644 

injuries,  table  of,  630,  631 

osteomyelitis,  643 

rheumatism  of,  651 

sarcoma  in  vicinity  of,  480 

senile  disease  of,  655 

skiagraphy  of,  653 

sprain  of,  621 

tuberculosis  of,  646 
Hirschsprung's  disease,  356,  y:,-] 

,  diagnosis    from    abdominal 

tumour,  287 
Hodgkin's    disease,    see    also    Pseudo- 
leuka;mia 

,  signs  of,  157,  158 

Horns,  cutaneous,  71 

—  — ,  on  heel,  739 

Hour-glass  stomach,  302,  303,  304 

— ■  — ■  — ,  causes  of,  305 

Humerus,  dislocations  of  539,  540 

,  varieties,   538,   S39,   542,   546 

— ,  fractures  at  lower  end  of,  555-568 

upper  end  of,  540-546 

— ,  muscular  hernia  over,  574 

— ,  myositis  ossificans  over,  574 

— ,  osteomyelitis  of,  576 

— ,   sprain  of,   546 

— ,  tumours  of,  572 

— ■  — ,  bone,   576 

,  muscles  and  nerves,  572 


INDEX 


759 


Humerus,    tumours   of,    skin   and    sub- 
cutaneous tissue,  572 
Hydatids,  see  Echinococcus 
Hydro-adenitis  of  axilla,  211 
Hydrocele,  bilocular  in  inguinal  canal, 

374,  387,  388 
— ,  communicating,  374,  387 
— ,  diagnosis    from    strangulated 
hernia,  398 

—  of  spermatic  cord,  385,  387,  415 
— •    women,  374 

—  testis,  387,  388 

— ,  relation     of     vaginal     process     of 

peritoneum,  387 
Hydrocephalus  in  meningocele,    53 
Hydro-myelomeningocele,   483 
Hydronephrosis,  closed,  454 
,   diagnosis  from  ovarian  tumour, 

28g 
— ,  intermittent,  448,  460 
— ,  open,  448 
— ,  remittent,  448 
Hydrops  of  bursa  iliaca,  652 
• —    gall-bladder,  323 
,   diagnosis  from  movable  kidney, 

323 

—  knee-joint,  679 

,  intermittent,  678 

,  traumatic,  681 

,  tubercular,  680 

—  prepatellar  bursa,  667 

-—    subdeltoid,  diagnosis  from  effusion 

into  shoulder-joint,  547,  548 
Hygroma  of  neck,  congenital,  161 
Hyperextension  fracture,   558,  561 
Hyperkeratosis  of  hand,  601 
Hypernephroma,  458 
— ,  secondary,  204 
Hyperthyroidism    in    Graves's   disease, 

143,   144 
Hypochondrium,  inflammatory  foci  in, 

265 
Hypospadias,  426,  475 
Hypothyroidism,       predisposition       to 

fracture    of    cartilage    of    femoral 

condyles  in,  670 
Hypertrophy      of      bronchial      glands 

diagnosis     from     mediastinal 

tumours,  200,  201 

—  of  prostate,  468,  469,  470 

—  spleen,  330,  331 

—  thymus,  200 

— •  — ,   diagnosis,  201 

—  thyroid,    142 


Hysteria,  abdominal  pain  in,  259 
— ,   diagnosis,  from  epilepsy,  34 

hip  disease,  652 

— •  —     intestinal  obstruction,  367 
—  —    paralysis,   548,   549 


iLEO-CiECAL  region,  tumours  of,  2>n 

Heo-sacral  tuberculosis,  517 

,  burrowing  abscess,  516,  518 

Incised  wounds  of  abdomen,  253 

— •  — ■  thorax,  189 

Incontinence  of  faeces,  493 

— ■    urine,  431 

— ,  paradoxical,  431,  492 

Infantile  paralysis,  club-foot  following 
on,  735 

— ■  — ,  spinal,  diagnosis  from  con- 
genital  dislocation  of  hip,  637 

,  unusual   localization  of,  375 

Infarct  of  bowel,  364 

—  kidneys,  453 
— •    testicle,  418 

Infiltration,      diffuse     gummatous     of 

tongue,   107 
Inguinal  abscesses,  516,  517 

—  hernise,  37Q-39I 
,  bladder  in,  391 

— ■  — ,  diagnosis       of       external,       in 

absence  of  swelling,  380 
,  in   the   presence   of   a  swell- 
ing, 382 
— • ,  labial    and    scrotal    herniae, 

387,  388 
— •  — ,   differential        diagnosis        from 

femoral  hernia,  385-394 

•  —  burrowing  abscess,  386 

— ■ varicocele,  388 

-of   external   and   internal, 

390,  391 
,  external,     379,     381,     382,     383, 

386,  387,  388,  389 
— ■  — -in  women  381 

,  intermuscular,   383,    384,    385 

,  internal,  390,  391 

,  preperitoneal,  381,  384 

,  relations  of,  to  abdominal  wall, 

381 
— •  — -  — ,  to       vaginal      process      and 

hydroceles,  387,  388 

,  scrotal,  387,  388 

■,  site  of  strangulated,  403 

,  subcutaneous,  381,  385,  386 

Intercarpal  joints,  dislocation  of,  584 


76o 


INDEX 


Intestinal  crises,  tabetic,  diagnosis 
from  obstruction,  358 

—  distension,  abnormal,  with  visible 
and  palpable  contractions  of  bowel 
above,  347 

,  murmurs,  at  seat  of,  347 

—  murmur  in  stenosis,  347 

—  obstruction,  346 
-,  acute,  357 

- — ■  — •  — ,  causes,  361 

(axial  rotation),  364 

(bands    and    kinks),    361, 

362 

(gall-stones),  362,  363 

— •  —  (intussusception),   363 

— ,  position    of     obstruction, 

358,  359 
--  — ■ ■    (strangulation    of    an  in- 
ternal hernia),  365,  366 

symptoms,  357,  358 

■  — ,  varieties,  360,  361 

— ■  — ,  arterio-mesenteric,   362 
— ■  — ,  chronic,  347 

,  appearance  of  bowel  in,  347, 

348 
,  condition   of   stools   in,   34S, 

349 

— ,  through  external  compres- 
sion, 353 

,  position  of  stenosis  in,  350 

— • ,  variety  and  cause  of  stenosis 

in,  351 

,  combined  with  external  hernia, 

409 

,  diagnosis      from      cholecystitis, 

318 

■  —    perforative   peritonitis,   358 

peritonitis,  255,  262 

,  effect  on  general  condition,  350 

,  hysterical,  367 

in  appendicitis,  337 

,  intermittent,  354,  361 

-in  tubercular  peritonitis,  285 

of  sudden  onset,  361 

,  spastic,  367 

,  transition  of  incomplete  to  com- 
plete, 360 

—  rigidity,   348 

—  stenosis,  cicatricial,  352 

,  concentric,       in      cancer      and 

tubercle  of  bowel,  after  reduction 
of  a  strangulated  hernia,  353,  406 

,  condition    found    on   palpation, 

351 


Intestinal  stenosis,  condition  of  stools 

in,  348,  340 

,  general   condition   in,   350 

of  gradual  development,  347 

large  intestine,  345,   406 

small  intestine,  348 

,  skiagraphy  in,  354,  355,  356 

— ■  —    through  tumours  in  bowel,  353 
Intestine,    abnormalities    of    position, 

236 
,   decussation     of     large     and 

small  intestine  in,  237 

,  position  of  appendix  in,  237 

— •  — •  — ,  principal  varieties,  236,  237 
— ,  appearance     of,     in     strangulated 

herniae,  403,  404 
— ,  axial  rotation  of,  364,  365 
— ,   carcinoma  of,  351,  352 
— ,  fibroma  of,  353 
— ,  fistulse  of,  378 
— ,  haemorrhage  of,  244 
— ,  herniae  of  intestinal  wall,  401 
— ,  infarction  of,  364 

—  injuries,   245,   246,   247,   353 

,  clinical  picture  of,   245 

— ,  intussusception  of,  275,  364 
— ,  lipoma  of,  353 

— ,  myoma  of,  353 

— ,  obstruction  of,  358 

—  paralysis     in     injuries     to     spinal 

column,  492 
— ,   sarcoma  of,  353 
— ,   syphilitic  stricture  of,  353 
— ,  tuberculosis  of,  286 
— ■  — ,   diagnosis  from  cancer,  351,  352 
— ,  ulcers  of,  351,  358 
Intussusception  of  bowel,  363,  364 

—  — ,   diagnosis  from  tumour,  287 
Iodoform   dermatitis,   602 

Isthmus  faucium,  inflammation  of,  yo 


JACKSONIAN  epilepsy,  15,  36,  37 
Jaundice,  catarrhal,  313 
— •  —    in  cholecystitis,  316 

,  infective,   317 

— ■  —    through  obstruction  of  common 

bile  duct,   321 
Jaw,  actinomycosis,  76,  78,  80 
— ,  ankylosing,  Ty 
— ,  antrum  of,  empyema  of,  83 

,  inflammation,    59 

— ,  arthritis,    76 


INDEX 


761 


Jaw,  cancer  of,  82,  83,  85 

— ,  cysts  of,  83,  84 

— ,  dislocation  of,  74 

— ,  fractures  of,   TZ-,   74 

— ,  inflammation,   acute,    78 

,  chronic,    78,    79 

— ,  lower,   chondroma   of,   87 

,  dislocation  of,  74 

-,  fibroma  of,   87 

,  fractures  of,   T}> 

,  multilocular  cyst,   87 

— -  — ,  osteoma  of,  87 

,.  sarcoma  of,  87,  88 

,  tumours    of,    diagnostic    signs, 

85-88 
— ,  multilocular  cystoma  of,  87 
— ,  osteoma  of,  87 
— ,  osteomyelitis,  76,  78,   131 
— ,  periostitis,    59,   60,   75,    78,    83,    84, 

131 

• — ,   phosphorus  necrosis  of,  81 

— ,  sarcoma  of,  86,  87 

- — ,  tuberculosis  of,  60,  76,   79,  80,  81, 

83 
— ,  upper,  carcinoma  of,  83 

,  empyema  of,  83 

,  fractures  of,    T2>,    74 

,  periostitis  of,   59,  83,  84 

— ■  — ,  sarcoma  of,  82,  83 

,  tuberculosis  of,  83,  84 

,  tumours  of,  82 

,  innocent,  85 

,  malignant,  83 

K 

Kidney,  abnormal  mobility  of,  444 

— ■    abscess,  452 

—    calculi,  453,  454 

,  composition,   451 

in  renal  tuberculosis,  460 

,  primary,  453 

,  secondary,  455 

,  X-ray  diagnosis,  454 

— ,  carcinomata,   456 

— ,  colic  of,  436,  453,  460 

,   diagnosis     from     biliary     colic, 

315 

peritonitis,   262 

— ,  cysts  of,  458 

— ,  displacements  of,  238 

,  acquired,  444 

,  congenital,    235 


Kidney,    displacements    of,    diagnosis 
from    distended    gall-bladder,    323 
— ,  examination  of  functions  of,   441 

—  haemorrhage,    249,    436 
— •  — •    in  hsemophilia,  436 

tuberculosis   of,  460 

tumours,  455,  456 

— ,  hydatid  of,  457 

—  infarcts,  453 

— ,  inflammation     around,     249,     266, 

442 
— ,  injuries  of,  248 

■ ,  extra-peritoneal,   249 

,  intra-peritoneal,    249 

— ,  pelvis  of,  inflammation  of,  452 
— •  — ,  new  growths  of,  456 

,  suppuration   of,   450 

— ,   sarcoma  of,  456,  457 

— ,   spontaneous  suppuration  of,  450 

— ,  bacteriology  of,  451 

—  —  — ,   diagnosis,    452 

— ,  tuberculosis  of,  443,  450,  458 

—  tumours  mixed,  289 
■    of,  455 

3  diagnosis,  456,   457 

,  displaced,   458 

Klumpke's  paralysis,  posture  of  hand 

and   fingers  in,    594 
Knee-joint,      abscess,       peri-articular, 

679 
— •  — ,  aneurism,    687 

—  — ,  bursal    inflammation,   667,    687, 

688 

— •  — ,  chronic  rheumatism  of,  679, 
680,  688 

— -  — ,  contracture  of,  686 

— •  — ,  contusion  of,  668 

,  detachment  of  internal  semi- 
lunar cartilage,  670 

■ ,  its      incarceration, 

670,  678 

— -  — •  — ■    cartilage  of  femur  in,  669 

,  dislocation  of,  674,  676 

,  effusion,  acute,  667,  679 

— ,  chronic,   679 

— •  — •  — ,  idiopathic,  680 

•  — ■,  traumatic,   681 

— •  — ,  fibroma  of  synovial  membrane, 
687 

,  foreign  body  in,  669,  678 

,  fractures  of,  670,  672,  673,  676 

,   fungating,  685 

— ■  — ,  gonorrhoea   of,    678,   681 


762 


INDEX 


Knee-joint,  gumma  of,  684 

in  haemophilia,  680,  681,  686 

,  injuries  of,  667,  676 

,  intermittent  hydrops  of,  678 

,  tubercular,  679,  682 

■ — •  — ,  lipoma     arborescens     of,     686, 

687 

,  normal,  683 

,  osteomyelitis  of,  678,  681 

,  rigidity  of,  684,  686 

■ — ■  — ,   sarcoma  of,   684,   687 

,  sesamoid  bone,  66g 

,  sprain,  668,  669,  670 

,  results  of,  671 

,   syphilis   of,   680,   681 

,  tuberculosis    of,    680,    681,    682, 

683,  684,  685 

•  — ,  ankylosing,   686 

,  tumours    and    allied    structures 

in  neighbourhood  of,  687,  688 


Labyrinth,  injuries  of,  s 

Large   intestine,    displacements,    chief 

varieties,  236 
in    skiagram,    240,    241,    242, 

243 

— ■  — ,  disturbances  of  function,  with 
anatomical  changes,  339 

• ,  without  typical  anatomi- 
cal changes,  342 

,   diverticula    of     (inflammation), 

276 

,  stenosis  of,  350,  351,  352,  355 

— •  — •  — ,  diagnosis  from  stenosis  of 
small  intestine,  358 

— •  — ,  syphilis  of,  341 

,  tubercle  of,  341 

Laryngoscopy  in  laryngeal  diseases, 
no 

Larynx,  carcinoma  of,   119,  139 

— 3  circulatory  disturbances  of,    115 

— ,  diphtheria  of,  in 

— -  — ,  diagnosis  from  lacunar  tonsil- 
litis,  III,  112 

— ■  • —  —    pneumonia,    113 

,  secondary  symptoms,   113 

--,  false  croup,   112 

— ,  fibroma  of,  121 

— ,  foreign  bodies  in,  116,  117 

— ,  fracture  of  cartilage  of,  116 

- — ,  inflammation  of,  in 


Larynx,   injuries  of,    116 
--,  oedema  of,  114,  115 

,  angioneurotic,    115 

— ,  papilloma  of,   121 

— ,  stenosis  of,  115 

— ,  surgical  diseases  of,   no 

—  — ■  — ,  acute,  1 1 1 
— ■  — •  — ,  chronic,   118 

— ,   syphilis  of,   118,   119,  120 

-~,  tubercle  of,   119,   120 

— ,  tumours  of,   121 

— ,  ulcers  of,   115 

— •  — ,   differential  diagnosis,   120 

— •  — ,  position,   120 

Leg,  abscess  of  bone  of,  704 

— ,  bony  cysts  of,  699,  700 

— ,  carcinoma  of,  696 

— ,  chondroma  of,  700 

— ,  diffuse  inflammation,  701 

— ,  dislocations  of,   712-716 

— ,  exostosis  of,  700 

— ,  fibroma  and  fibro-neurorha  of,  697, 

700 
— ,   fractures  of,  706-712 
— ,  gumma   of,    703 
— ,  localized   inflammation,    703 
— ,  osteomyelitis  of,  700,  701,  702,  703 
— ,  sarcoma  of,  699,  705 
— ,  swellings     and    tumours    of,    697, 

698,   703 
— ,  syphilis  of,  695,  6g6,  701 
— ,  tuberculosis  of,  703,  704         , 
— ,  ulcers  of,  693 

,  malignant,    696 

,   syphilitic,   695,   6g6 

,  varicose,  693,  694,  695 

— ,  varicose  veins  of,  691 

Length  measurements  of  lower  limbs 

after  injuries,  612,  613 
Leprosy  of  hand,  606 
— -    of  nose,   103 

Leukaemia,  glandular  swelling  in,   157 
— ,  haemorrhage  from  gums  in,  100 
— ,  pharyngeal  swelling  in,  95 
— ,  splenic  enlargement  in,  331 
Leukoplakia  of  tongue,    104 
Ligamentum   patellae,    detachment   of, 

674 

—  teres,   fibromyoma   of,  375 

—  tibio-fibulare    anticum,     laceration, 
of,  712 

Limping,  610 

— J  intermittent,  691 


INDEX 


7t>3 


Limping,  painful,  6ii 

— ,  paralytic,  6io,  637 

— •    through  rigidity  of  limbs,  611 

— ■  —  shortening,   610 

— ,  unilateral,  640,  642 

— ,  voluntary,  646 

Lipoma  in  femoral  canal,  394 

,  diagnosis  from  hernia,  393 

— •    of  abdominal  wall,  369 

—  axilla,   572,  573 

—  back,  216,  217 

—  neck,   134,   173,   174 

,  periglandular,  174 

— ■    breast,  211,  234 

—  epigastrium,  369,  370 
,   subserous,  370,   371 

—  face,  63 

—  floor  of  mouth,  92,  93 

—  foot,  739 

—  hand,  509,  608 

—  knee-joint,  686,  687 

—  lumbar  region,  376 
— ■    neck,   166 

—  pharynx,  97 

—  sacral  region,  486 

—  shoulder,   572 

—  spermatic  cord,  389,  391,  416 

—  thigh,  657 

—  tongue,   105 

—  upper  arm,  573 

- — ■,  perihernial,  393 

Lips,  cancer  of,  64,  67,  68,  99 

— ,   furuncle  of,   59,  89 

— ,  gangrene  of,  91 

— ,  primary  chancre  of,  64 

— ,  tumours  of  mucous  membrane  of, 

92,   93,  99 
Lisfranc's  joint,  dislocation  of,  721 

,  inflammation  of,   724 

Little's  disease,  spastic  club-foot  after, 

735 

Littre's  hernia,  intestinal  obstruction 
in,  401 

Liver,  abscess  of,  265,  326,  327 

— ,  acute  yellow  atrophy,  313 

— ,  adenoma  of,  326 

— ,  carcinoma  of,   326 

— ,  cirrhosis  of,  314 

— ,  constricted  lobe  of,  325 

— ,  cysts  of,  326 

,  parasitic,  326 

— ,  diagnosis  from  tubercular  peri- 
tonitis with  effusion,  283 


Liver,  displacements  of,  236,  238 

— ,  floating,  238,  325 

— ,  gumma  of,  326 

— ,  hydatid  cyst  of,  326 

,  multilocular,  326 

— ,  injuries  of,   247,   253 
— ,  tumours  of,  325 

—  — ,  primary,  325 

,   secondary   malignant,   325 

Lordosis  of  spine,  524,  525 

Lumbago,  486 

— ,  course  of  symptoms,  487 

— ,   diagnosis   from  renal   tumour,   456 

— ,   rheumatic  and  traumatic,  487,  488 

Lumbar  kyphosis,  525 

— •    lordosis,  525 

in  congenital  dislocation  of  hip, 

634,  635 

—  pains  in  renal  disease,  456,  460 

—  puncture  in  cerebral  pressure,   16 

—  —  meningitis,  33 

—  region,   abscess,   perinephritic,  375 
— ■  — ,  areas  of  inflammation  in,  retro- 
peritoneal, 266 

,  burrowing  abscess  of,  375 

,  false  hernia,  375 

— ■  — ,  hernia  of,  375 
— •  — ,  lipoma  of,  376 

,  pigmented  nsevus  of,  214 

,  reflex      muscular      rigidity      in 

unilateral  renal  injury,  249 

—  scoliosis,  523,  527,  528,  532 
— -    vertebra,  caries  of,  516,  517 

—  — ,  compression    fracture   of,    501 

,   determination  of  injured,  500 

,  dislocation  of,  500 

Lumbo-dorsal  scoliosis,   529,   532 
Lumbo-sacral  cord,  segmental  diagno- 
sis of  lesions,  405 

,   symptoms  of  injury  of,  498 

■  — ,  types  of  paralysis,  499 

Lung,  abscess  of,   195 

-in  skiagram,   196 

— ,  actinomycosis  of,   198,  210 
— ,  bronchiectasis  of,   198 
— ,  cancer  of,  207 

,  metastatic,  207 

— ,  chondroma  of,  207 

— ,  dermoid  of,  207 

— ,  embolism  of,   197 

— ,  empyema,   195 

— ,  foreign  bodies  in,  117,  196 

— ,  gangrene  of,   196,   197 


764 


INDEX 


I,ung,  hydatid  of,  207 
— ,  injuries  of,   i8q 

,  diagnostic  signs  of,   190 

,   secondary  injuries,   iqo 

— ,  sarcoma  of,  207 

— ,  surgical  diseases  of,  195 

-— ,  tubercular  cavities  in,    198,   209 

-—,  tumours  of,  199,  207 

,   differential  diagnosis,  208 

Lupus  of  cheek,  71 

—  of  face,  hypertrophic,  67,  72 

—  hand,  606 

—  nose,  65,  72 

Lymphadenitis,     acute     submaxillary, 
90,  132 

—  in  neck,  155,  182 

,  malignant,    159 

-—    of  axilla,  550 

— ,  phlegmonous   submental,   89,   131 
Lymphangioma  of  ear,  64 


floor  of  mouth 
neck,  160 
sacral  region,  / 
scrotum,  415 
thigh,  657 
thorax,  cystic. 


89,  93 


217 


—  tongue,   105,   106 
Lymphangitis  of  arm,  tubercular,  569 
Lymphatic  cysts  of  neck,  161,  162 

—  gland,      enlargement      in      axilla, 
211,  212 

—  cancer  of  breast,  229 

— inguinal   region,   375,   392 

neclv,  diagnostic  significance, 

155 

,  sarcoma  in  neck,  170 

■  —  thigh,  657 

ulcers  of  tonsil,   loi,   102 

,  causes  of,  155,   156 

Lymphoma,  malignant,   158,   159,   160 
,   diagnosis  from  lymphosarcoma, 

170 

—  of  neck,  tubercular,  156 
Lymphosarcoma  of  neck,    170 

—  lung,  207 

M 

Macroglossia,  104 
Madura  foot,  725 
Malarial  spleen,  331 

,  rupture  of,  247 

Malleoli,  fractures,  706,  707, 
710,  711 


708,  709, 


Malleoli,  fractures,  position  and  direc- 
tion  of   lines   of   fracture,    710 

Mamma,  abscess  of,  211,  219 

,  retro-mammary,  221 

— ,  actinomycosis   of,   222 

— ,  carcinoma  of,  226,  227,  228,  232 

— ■  — ,  important  diagnostic  signs, 
229-232 

,  scirrhus,  229,  231 

—  — ,  secondary,  231 
— •  — ,  ulcerating,  230 
— ,  chondroma  of,   234 

— ,  cysto-adenoma   phyllodes   of,   232 

— ,  cysto-sarcoma  phyllodes   of,   232 

— ,  cysts  of,  223,  224,  225 

— -  — ,   solitary,  226 

— ,  fibro-adenoma    of,    223,    224,    226, 

232,  233 
— ,  giant  growth  of,   232 
— ,  gumma  of,  222 
— ,  inflammation  of,  219 
,  acute,   21Q 

—  — ,  chronic,  221 

— ,  lipoma  of,  211,  234 

— ,  sarcoma  of,  232 

— •  — ,  secondary,  233 

— ,  tuberculosis  of,  221,  222 

— ,  tumours  of,  223 

— ■  — ,  isolated,  224 

— ■  — -of  the  male  breast,  234 

,  multiple,   224 

,  types  of,   223 

Manubrium  sterni,  osteomyelitis  of. 
133 

,  see  also   Sternum 

Manus  valga,  596,  597 

—  vara,  595 
Mastitis,  acute,  221 

— ,   chronic  cystic,   223 

—  neonatorum,  219 
— ,   puerjDeral,   220 

Mastoiditis,    brain    symptoms    of,    25,. 

29,  30 
Mastoid  process,  inflammation  of,  28 
Median    nerve    paralysis,    posture    of 

hand  in,   593 
Mediastinum,  dermoid  of,  207 
— ,  hydatid  of,  207 
— ,  injuries  of,    191 
— ,  phlegmon   of,    127,    133 
— ,  sarcoma  of,  207 
— ,  tumours  of,  199,  204 

—  — ,  malignant,  207,  208 


INDEX 


/"O 


Mediastinum,  tumours  of,  malignant, 
diagnosis  from  deep  and  intra- 
thoracic goitre,  205 

•    enlargement  of  bronchial 

glands,  201 

■  — ■    of  thymus,  201,  202 

innominate      and      aortic 

aneurisms,  201,   202 

Medullary  cancer  of  breast,  231 

—  —    penis,  477 

—  sarcoma  of  upper  end  of  tibia,  6Qg 
Meningitis,  diagnosis  of,  3^ 

— ,  purulent,  resulting  from  otitis 
media,   29,  30,  31 

— ,  serosa   circumscripta   spinalis,    510 

Meningocele,  52,  174,  482,  484,  485 

— ,   spurious,  53 

Meningoencephalocele,    174 

Menstruation,   intra-abdominal,   263 

— ,  painful,  diagnosis  from  peritonitis, 
263 

Meralgia  paraesthetica,  692 

Mercurial  stomatitis,  76,  qi 

Mesenteric  cysts,  285,  287 

— ■    vessels,   thrombosis  of,  353 

■  — ,  diagnosis   from   ileus,    358 

■  peritonitis,  264 

Mesentery,  common,  236 

— ,  detachment  of,  353 

— ,  ileo-caecal,   237 

Metacarpus,    fracture  of,    586 

— ,  osteomyelitis  and  periostitis  of, 
60s 

Metatarsus,  fracture  of,  722,  723,  724 

— ,  inflammatory  processes  of,  728 

— ,  tumours  of,  738 

Middle  ear,  inflammation,  purulent, 
brain  complications  of,  20,  21,  25, 
26,  27 

Mikulicz's  disease,   167 

Mind  blindness,  39 

Mixed  tumours  of  kidneys,  289,  457 

palate,  95 

parotid,   168 

• submaxiliary   region,    167 

Molluscum  contagiosum  of  face,  dia- 
gnosis from  cutaneous  cancer,  70, 
71 

Motion,  power  of,  after  cerebral  in- 
juries, 44,  45 

vertebral  injuries,  493,  495 

Mouth  cavity,  acute  swelling  in  floor 
of,  89,  90 


Mouth  cavity,  angina  of,  90,  gi 
— •  — ,  angioma  of,  93 

,  cancer  of,  gg 

■  — ,  perforating,   139 

—  — ,  cysts  of,  92,  93 
— ■  — ,  dermoid  of,  89 

■  — ,  sublingual,  93 

— ■  — ,  examination  of,  in  dysphagia, 
124 

—  — ,  fibroma  of,  92,  94 

,  gangrenous  stomatitis  of,  91 

,  gumma  of,  95,  98,  100 

,  haemorrhage  from,  due  to  frac- 
tured base  of  skull,  3 

,  inflammatory    processes  in,    88- 

91 
— -  — ,   lipoma  of,  g2,  g3 

,  lymphadenitis  of,  8g,  go 

— ■  — ,  lymphangioma  of,  8g,  93 

—  — ,  noma,  91 

— •  — ,  primary  chancre  of,    100,   loi 

,   salivary    glands    inflammation, 

89 

,  tubercle  of,  98,  100 

— •  — ,  ulcers  of,  98,  99 

Mucous  colic,  diagnosis  from  peri- 
tonitis, 262 

— ■    cysts  of  mouth  cavity,  92 

—  polypus  of  nose,  08 

pharynx,  97 

rectum,   407 

Muscle  of  thigh,  osteoma  of,  658 
Muscles  of  neck,  gumma  in,  140 

—  thigh,  gumma  in,  658 

—  thorax,  gumma  in,  212 
Muscular  angioma  of  arm,  572 
thigh,  658 

—  atrophy,  progressive,  with  lordo- 
sis, 522,   524,  63s,  639 

— •    hernia  of  thigh,  658 
upper  arm,  574 

—  paralysis  of  abdomen,  localized, 
375 

—  tuberculosis    of    abdominal    wall, 

375 

—  —    arm,   573 

—  — ■    neck,  140 

thigh,  658 

— ■  — •    thorax,  212 
Myelitis,  chronic,   509 
— ,  traumatic,  4g7 
Myelo-cystocele,  483 
Myelo-meningocele,   483,    484,    485 


766 


INDEX 


Myoma  of  bladder,  467 

— •    intestine,   353 

— •    uterus,  289,  468 

— ■  — ,  constipation   in,  407 

Myositis  in  wry  neck,  181,  185 

—  of  sterno-mastoid,   133 

—  ossificans  of  arm,   574 

N 

N^vus  of  abdominal  wall,  becoming 

sarcomatous,   376 
— ,  pigmented,  214 
— ,  vascular,  54 
Nail-bed,  inflammation  of,  602 
— ■  — ,   syphilitic,   603 
— ,  tumours  of,   139 
— •,  ulcers  of,  740 
Naso-pharyngeal  fibroma,  84,  97,  123 

—  —    polypi,  96,  97,   123 
Neck,  abscesses  of,  130,  133,  516 
•    after  aural  suppuration,  2>2> 

—  — ,  chronic,   134,   135 

due  to  spinal  caries,  514 

— •  — ,  tubercular,    134,    140 

— ,  actinomycosis  of,  80,  135 

—  —    with   sinus   formation,    137 
— ,  aneurism  of,  140,  162,  163 
— ,  back  of,  abscesses  in,  133, 
— ■  — ,  carbuncle  of,  136 

—  — ,  cerebral   hernia  in,   52, 
— ■  — ,   dermoids  in,   134,   174 
— -  — ,   fibroma  of,   175 

,  lipoma  of,   134,  173,   174 

•  ,  rigidity  of,  with  gradual  onset, 

181 
— •  — ■  — ,   with  sudden  onset,   176 
-^  — ,  sarcoma  of,   175 

,  sebaceous  cysts  in,   174 

— ,  blood  cysts  of,   161 

— ,  branchiogenous  carcinoma  of,    171 

— 5  cavernous   angioma  of,   162 

— ,  congenital  hygroma  of,   161 

— ,  cysts   of,    155,    160,    161,    163,    164, 

165 
— ,  dermoid  of,   165 
— ,  diffuse      carcinomatosis      of      the 

lymphatic     glands,     160 
— ,  enlarged  glands  of,   113,   131,   132 
- — ,  fibroma  of,   166,   169,   170 
— ,  fibroma-sarcoma  of,   170 
— ,  gumma  of,  136,  140 

—  — -in  muscle  of,  140 


134 


174 


Neck,    gumma   of,    inflammatory   pro- 
cesses of,  127,  131,  135,  166 
— ,  lipoma  of,   166 
— ,  lymphangioma   of,    161 
— ,  lymphatic  cysts  of,  161,  162 
— •  — ■    glands    of,    swelling,    102,    155, 

156,    157,    158 
— -  —  — ,  malignant,   159 
— ,  lymphosarcoma  of,  170 
— ,  neuro-fibroma  of,   i6q,   170 
— ,  phlegmon  of,  127,  130,  133 
— ,  pseudo-tumours  of,   139 
— ,   sarcoma  of,    169,    170 

—  — ,  deep,  163 

— •  — ,  vascular,    163 

— ,  sebaceous  cyst  of,  165 

— ,  surgical  diseases  of,    no 

— ,  syphilis  of,  136,  156 

- — ,  tubercle  in  muscle  of,  140 

—  —    of,  136,  141,  156 
— ,  tumours  of,   139 

— ■  — ■    back  of,    174 
— •  —    side  of,  155,  169 

,  in  anterior  triangle,  140,  155 

,  solid,   166 

,  with  liquid  contents,   159 

Nephritis,   chronic  haemorrhagic,   436 
Nerves  of  base  of  skull,  46 
Neuralgia    of    anterior    crural    nerve, 

692 
— -    external  femoral  cutaneous,  692 
— ■    inferior  dental  nerve,  73,  86 

—  infra-orbital    nerve    in    malignant 

growths  of  upper  jaw,  82 
— ■    obturator  nerve,  692 
— -    sciatic  nerve,  68g 
— ,  peri-articular     of     hip,      diagnosis 

from  dip  disease,  652 
Neuro-fibroma  of  arm,  572 

—  back,  217 

—  leg,  697,  700 

—  neck,  169 

—  thigh,  659 
Neuroma  of  arm,  572 
Nipple,  retraction  of,  229 
Noma  of  lips  and  cheeks,  91 
Nose,  cancer  of,  67,  68,  69,  70,  160 
— ,  glanders  of,    103 

— ,  haemorrhage  from,  in  fractured 
base  of  skull,  diagnostic  sig- 
nificance of,  3 

— ,  leprosy  of,   103 

— ,  lupus  of,  65,  72 


INDEX 


767 


Nose,  lupus  of,  hypertrophic  forms,  67 
— ,  mucous  polypi  of,  97,  98 
— ,  rhino-scleroma  of,  103 
— ,  sarcoma  of,   97,  98 
— ,  sebaceous  cyst  at  root,  64 
— ,  syphilis  of,  65,  66 
— ,  tubercle  of,    103 

Nystagmus,      local       diagnostic      sig- 
nificance of,  in  brain  lesions,  40,  41 

o 

Occipital  bone,  cerebral  hernia  at,  52 
,  osteo-myelitis  of,    134 

—  lobe,  tumours  of,  24 
Oculo-motor  nerve,  injuries  of,  s 
Odontomata,  86,  87 

CEdema  of  back  of  hand,  586,  605 

— ■    glottis,  114 

— ■    larynx,  angioneurotic,   115 

CEsophagus,  carcinoma,  129,  130 

— ,  compression,  128,  129 

— ,  difficulties      in      swallowing      in 

neighbourhood  of,   124-130 
— ,   diverticula  of,  128,   135,  140,   162 
— ,  foreign  bodies  in,   124,    126 

—  — ■  — ,  diagnosis  of,  124,  125 
■,  removal  of,  127 

— ,  injuries  of,  191 

— ,  spindle-shaped  dilatation  of,  128 

— ,  stenosis  of,  127 

— ,  stricture  of,  syphilitic,  130 

—  — ,  corrosive,  127,  130 
Olecranon,  fracture  of,   556,  557 
— ,  tubercle  of,  572 

Oliguria,  432 
Omental  cysts,  287 
— •    hernia,  389 

,  strangulated,  402,  403,  421 

— •  tumours,  287 

— ■  — ,  torsion    of,    and    its   symptoms, 

358,  402 
Onychia  maligna,    740 
Optic  nerve,  injuries  of,  5 
— •  — ■  — ,  localization,  38,  39 
— ■    neuritis,  diagnostic  significance  in 

cerebral  abscess,   18 

■    tumours,    18,    19 

Orbit,  angioma  of,   50 
— ,  injuries  of,  4 
— ,  osteoma  of,  50 
Orchitis,  417 
— ,  metastatic,    417 


Os  calcis,  see  Calcaneus 
Osteo-chondritis    dissecans     of     knee- 
joint,   669 
Osteoma  of  arm,  traumatic,   574 
-~    cervical   rib,    173 
— •    lower  jaw,  87 
— ■    orbit,  so 

—  skull,  55 

—  thigh,  658,  659 
— ■    thorax,  218 

— ■    vertebra,   511 
Osteomyelitis  of  arm,   576 
— •    clavicle,  133,  210 

—  femur,  656,  657 

—  finger,   604,  605,   609 
— ■    hand,    605 

—  hip-joint,   643,   644 

—  humerus,  553,  575,  576 

—  jaw,   78,    131 

— -    knee-joint,  665,  666,  680 
— ■    occipital  bone,   134 
— ■    ribs,  210 

—  scapula,  210 

— ■    shoulder-joint,   553 
— •    skull,  51 

—  spine,   180,  521 

—  sternum,    133 

—  thigh,   643,    644 

— ■  — ,  chronic,  662,  663,  664 

—  tibia,  700,  701,  702,  703 
Osteoporosis     in     fracture     of     elbow, 

591 

—  of  bones  of  foot,  725,  726 
--    carpus,  592 

Ostitis  fibrosa  of  femur,  660 
— -  —  finger,  purulent,  604 
humerus,   575 

—  of  mastoid,  prominence  of  concha 
in,  27,  28 

— •    ribs,  chronic,  213 
Os  trigonum,  710,  711 
Othaematoma,  64,  65 
Otitis    media,    chronic,   cerebral    com- 
plications of,   19,  25,  26-33 

— ,  symptoms  of,   27,   28,   29 

Ovarian  cysts,  289 

—  — ,   diagnosis  from  hydronephrosis, 

289 

—  — ,  torsion  of,  267,  299,  358 
-^    hernia,  diagnosis  of,  383 
Ovary,    cancer    of,    causing   intestinal 

obstruction,  353 


768 


INDEX 


Ovary,  fibro-sarcoma  of,  289 
— ,  strangulated,  403 

P 

Pachymeningitis,  hsemorrhagic,  dia- 
gnostic signs  of,  17,  2O3  21 

— ,  hypertrophic,   508,  509 

Palate,  abscess  of,  originating  in  root 
of  tooth,  95 

— ,   acute  inflammation  of,    123 

— ,  carcinoma  of,   103 

— ,  defects  in,   123 

— ,  paralysis  of,  122 

— ,  polypi  of,  06 

— ,  scar  development  in,   123 

— ,  syphilis  of,  103 

— ,  tubercle  of,  103 

— ,  tumours    of    and    their    diagnosis, 

95,  96 

Palati,  velum,  ulcerative  processes 
on,  103 

Palm,  callosities  of,  with  dilatation 
of  mucous  bursse  beneath,  605 

— ,  lipoma  of,  608 

Palmar  aponeurosis,  Dupuytren's  con- 
traction of,  597 

Panaritium  (Whitlow),  602,  603,  604 

Pancreas,  cancer  of  head  of,  329 

— ,  cysts  of,  329 

— ,  diagnosis  from  cholecystitis,  316 

— ,  haemorrhage  of,  264,  265,  328 

— •  — ,  intestinal  paralysis  in,   358 

— ,   stones  in,  329 

• — ,  surgical  diseases  of,  327 

— ,  tumours  of,  329 

Pancreatitis,   acute,   328 

— ,  chronic,  329 

,   fat  necrosis  in,  264 

— ,   diagnosis  from  cholecystitis,  316 

•    ileus,  358 

■    perforated  gastric  ulcer,  299 

■ — •  — •    peritonitis,   264 

— ,  urinary  reaction  in,  329 

Papilloma  of  bladder,  467 

—  larynx,  121 

—  palate,  96 
Para-goitres,   171 

Paralysis  in  cerebral  pressure,  12,  14, 
IS 

—  congenital  dislocation  of  hip,  637, 
638 

— ,  complete  injuries  of  spine,  493 


Paralysis,  ischaemic,  595 

— ,  partial  injuries  of  spinal  cord,  494 

—  of   arm,   diagnosis  from   traumatic 

neurosis,  549 

—  hand     and     fingers     after     nerve 
lesion,  592-595 

—  palate,  122 
— ,  types  of,  499 
Parametritis,  267,  271,  273 
Paranephritis,  442 
Paraphimosis,  474,  475 
Paraplegia  dolorosa  in  compression  of 

Cauda,  499 
— ,  spastic,  occurrence  of,  509 

—  — •  — -in  spinal  caries,  519 
Paresis  of  shoulder  muscles,  diagnosis 

of,  549 
Paronychia  syphilitica,  603 
Parotid,  abscess  of,  62 
— ,  cancer  of,  169 
— ,  chondroma  of,    169 
— ,  mixed  tumours  of,   168 
— ,  sarcoma  of,  169 
— ,  tubercle  of,  167,  168 
Parotitis,  62,   132 
— ,  epidemic,  62 
Patella,  dislocation  of,  676 
— ,  fracture  of,  672,  674 
— ,  laceration  of  ligamentum  patellae, 

674 
— ,  riding    of,     in    articular    effusion, 

667 
— ,  sarcoma  of,  687 
Patellar  reflexes  in  vertebral  injuries, 

493 
Pelvic  cellular  tissue,  tumours  of,  481 
•  — ,  dermoids  of,  481 

—  cellulitis,  271,  273,  275 

—  viscera,   surgical   diseases  of,   235, 
273,  274,  275,  276 

Pelvis,  abscesses  of,  517 

— ,  burrowing  abscesses  in,  479 

— ,  crushing  of  acetabulum  of,  637 

— ,  exudation  in,  407,  431 

— ,  fibroma  of,  480 

— ,  fractures  of,  628 

—  — ■    pelvic  fossa,  630,  631 
■  —    ring,  629,  631 

— ,  inflammatory  process  in,  true,  275, 

276 
— ,  injuries    of    urethra    in    fractures, 

474,  630 


INDEX 


769 


Pelvis,  sarcoma  of  bones  of,  480 

—  —    muscles,  480 

— ,  sinuses  of,  424 

— ,  true,  cysts  of,  407 

— ,  tumours  of,  480,  481 

— •  — ,  examination  of,  479,  480 

in    true,    symptoms    caused    by 

compression      and      displacement, 

407,  431,  478 
Penis,  constriction  of,  474 
— ,  deformities  of,  475 
— ,  injuries  of,  474 
— ,  osseous  nodules  in,  475 
— ,  subcutaneous  tumours  of,  475 
— ,  surgical  diseases  of,  474 
— ,  ulcers  of,  476 

,  cancerous,  476,  477 

,  tubercular,  476 

Perichondritis,   laryngeal,    114,    132 

Pericolitis,  344,  345 

Perimetritis,   intestinal  obstruction  in, 

354 
— •    with  peritonitis,  271 
Perinephritis,  442 
— ,  diagnosis  from  pleurisy,  442 

—  — ,    tubercular  hip,  652 
— ,  ileus  in,  354 

— ,  in  renal  tuberculosis,  461 

— ,  origin  of,  443 

Periorchitis,  420 

— ,  secondary,  421 

— ,   serous  and  proliferating,  421 

Periostitis  of  bones  of  skull,  51 

— ■    humerus,  575 

— ■    hyoid,  132 

— ,  see  also  Osteomyelitis 

—  jaw,  59,  60,  78,  79,  83,  85,  86,  131 
- —    metacarpals,  605,  609 

—  tibia,  703,  704 
Periproctitis,  275,  431 
Perisalpingitis,  271 

Peritoneum,  congenital  pouches  of, 
strangulation    of  bowel   in,   366 

■ — ,  inflammation  of,  254-265 

,  spreading   from   one  area   over 

whole  abdomen  (types),  255 

— ,  tuberculosis  of,  264,  281 

Peritonitis,  254-261 

— ,  adhesive,  284,  285 

— ,  commencing,  255 

• — ,  determination  of  leucocyte  blood 
count  in,  261 

^—,  physical  condition  in,   257-261 


Peritonitis,   diagnosis  from  dysmenor- 
rhoea,  263 

—  —  gall-bladder  pain,  262 
■  hysteria,  262 

ileus,  286 

intestinal  obstruction,  255,  263 

— ■  —  mucous  colic,  262 

— •  —  pneumonia  and  pleurisy,  263 

•  renal  colic,  262 

•  spinal  caries,  263 

— ■  — -  tabes,  262 

—  — ■  of  cases  of  abdominal  pain  with- 

out evident  changes  from  stranga- 

lated  hernia,  263 
--,  diffuse,  254,  255 

,  without   localization,   263,  264 

— ,  examination  in,  282 
— ,  exudative,  283 

—  in  a  hernial  sac,  401 

— ,   indications    for   exploratory    punc- 
ture in,  286 
— •    in  intestinal  injuries,  246 
— ,  localized,  265 

,  in  epigastrium,  265 

— ■  — ,  hypochondrium,  265 
— ■  — ,  hypogastric  region,  266 
— ■  — ,  lumbar  region,  266 

—  — ,  true  pelvis,  275 
— ,  nodular,  284 

— ,  origin  of  tubercular,  285 

— ,  perforative,  254,  258 

— ,  peripheral   (Lennander's),  259,  297 

— ,  prognosis  of,  261 

— ,  residual   abscesses  after,  256,  270, 

334 
— ,  sero-purulent,  255 
— ,  serous,  255,  268 

,   in  appendicitis,  270,  334 

— ,  significance    of    age    and    sex    in 

diagnosis  of,  256 

history  in  diagnosis  of,  255,  256 

— ,  tubercular,  264,  281,  282 

,  with    saccular    exudation,    283, 

285,  290 
Phantom  hernia  of  lumbar  region,  374 
— •    tumours  of  abdomen,  287 
— •    of  neck,   139 
Pharynx,  abscess  of,  gi,  96 
— ,  adenoids  in,  gi 
— ,  cancer  of,  142 
— ,   diphtheria  in,   iii 
— ,  examination  of,  in 

—  — ,  in  dysphagia,    125 


770 


INDEX 


Pharynx,    foreign   bodies   in,    123,    124 
— ,  inflamed,    diffuse    and    unilateral, 

90 
— ,  inflammatory  processes  in,    iii 
— ,  polypus  of,  96,  97 
— ,  pressure  sore  in,  103 
— ,  sarcoma  of,  95,  96 
— ,  syphilis  of,  90,  98,  loi,  103 
— ,  teratoid  tumours  of,  97 
— ,  ulcers  in,   and  their  diagnosis,  98, 

99,   loi,   102,  103 
Phlegmon  in  axilla,  210 

—  ligneux,   135,  288 

—  of  floor  of  mouth,  90 

—  front  of  arm,  568 
--    frontal  sinus,  60 

—  mediastinum,   127,   133 
— ■    scalp,  51 

—  supraclavicular  region,   133 
Phosphorus  necrosis  of  jaw,  81,  100 
Pituitary    gland    and    its    relation    to 

obesity,  175 

— ■  — ,  injuries  of,  38 

,  tumours  of,  24 

Pleura,    inflammation    of,    after    peri- 
tonitis, 260,  263 

— ■  — ,  purulent,  209 

— ,  injuries  of,    189 

—  — ,   with  cardiac  wounds,   193 
Pleural       exudation      in       subphrenic 

abscess,  279 
Pneumococcal  peritonitis,  267,  285 
Pneumonia,  croupous,   196 
— ,   diagnosis  from  diphtheria,   113 

peritonitis  in  children,  263 

— ,  metastatic,  260 
— ,  purulent,  195 

— ,  resulting  in  spinal  caries,   521 
— ,  traumatic,  117,  189 
Pneumothorax,   traumatic,  189 
Pollakiuria,  433 
Polyposis  of  rectum,  408 
Polypus  at  neck  of  bladder,  462 
— ■    in  nasopharynx,  96,  97,  98,   123 

—  of  ear,  26 
Polyuria,  433 

Pons,  injuries  of,   focal  symptoms,   44 
— ,  tumours  of,   diagnostic   signs,   24 
Porencephaly,   traumatic,   35,    54 
Pott's  deformity,  511 
Pouches,    ileo-appendicular   and    right 
retrocaecal  hernia  in,  366 


Precentral    sulcus,    determination    of, 

on  skull,  47 
Pressure    diverticulum   of   oesophagus, 

128 
Processus  vaginalis  of  peritoneum  and 

herniae,  387 
Proctitis,    gonorrhoeal    and    syphilitic, 

408 
Prolapse  of  anus  and  rectum,  411 
Prostate,  abscess  of,  431,  471 
--  — ,  diagnosis,  276,  439 
— ,  carcinoma  of,  470 
— ■,  cysts  of,  481 
— ,  examination  of,  .438,  439 
— •,  gonorrhoea  of,  471 
— -,  hsemorrhage  from,  470 
— ,  hypertrophy  of,  430,  431,  438,  439 
— -  — ,  symptoms  and  course,  469,  470 
— ,  sarcoma  of,  470 
— ,  tuberculosis  of,  471 
Prostatitis,  411 
— ,  diagnosis  of,  439 
Pseudo-hermaphroditism,  383 
Pseudo-leukaemia,    glandular    enlarge- 
ment in,  157,  158,  203 
— ,  pharyngeal  swelling  in,  95 
— ,  splenic  enlargement  in,  331 
Psoas  abscess,  443,  517 
Pupils  in  cerebral  pressure,  13 
— ,  reaction    of    in    vertebral    injuries, 

502 
in    visual    disturbances    in,    39, 

40 
Pyelitis,  451,  452 
— ,  anatomical  diagnosis  of,  452 
— ,  gonorrhoeal,  451 
— ■    in  prostatic  hypertrophy,  450 

—  of  pregnancy,  451 
Pyelonephritis,  452 
Pyloric  cancer,  311 

— ■  — ,   signs  of  retention  in,   311 
— •  — 5  skiagrams  of,  302,  303,  312 

—  spasm,  301 

— ■    stenosis,  cancerous,  303,  311,  312 

,  innocent,   304 

— •  — -of  infants,  305 
Pyonephrosis,  449,  450 
Pyorrhoea  alveolaris,  100 
Pyosalpinx,  271 


Quadriceps  tendon,  laceration  of,  671 


INDEX 


771 


Rachischisis,  posterior,  482,  483 
Radial  paralysis,  posture  of  hand  in, 

593 

Radio-carpal  joint,  dislocation  of,  585 
Radius,  absence  of,  595 

—  fracture,  577,  578,  580,  581,  582 
,  combined,  579 

—  — •  — ,  caused  by  wrench,  579 

— ,  with  fork-like  posture,  577 

■  — ,  into  joint,   577 

— ,  head  of,  chisel  fracture,  565,  566 
— ,  individual  dislocation  of,   563,   576 
— ,  separation   of   epiphysis,    577,    579, 

s8o 
Ranula,  92 

— ,  differential  diagnosis,  92,  93,  94 
Raynaud's  disease,  603,  606,  607 
Reclvlinghausen's  disease,   55,    170 
Reclus's  disease,  223 
Rectal  fistulae,  410,  424,  425 
,  acquired,   inflamed,   424 

—  — ,  complete  and  incomplete,  426 

—  — ,  congenital,  424 

,  ischio-rectal     and     pelvi-rectal, 

426 
Rectum,  carcinoma  of,  408,  409,  411 
— •  — ,  causing  perirectal  suppuration, 

275 

— ■ stenosis,  352 

— ,  condition  of,  in  spinal  injuries,  492 

■— ,  fissure  of,  409 

— ,  fistulae  of,  410 

— ,  foreign  bodies  in,  412 

— •  — ■  — ,  introduced  into,  413 

— ,  gonorrhoeal  stricture  of,  407 

■ — ,  injuries  of,  412,  413 

— ,  polyposis  of,  408 

— ,  prolapse  of,  411 

— ,  sarcoma  of,  409,  411 

— ,  syphilis  of,  341,  353,  407,  408 

— ,  tenesmus  of,  407 

— ,  tuberculosis  of,  341,  407 

Recurrent  nerve  paralysis,  200 

— ■  — ■  — ,  symptoms  of,  118 

Reflex  epilepsy,  35 

—  symptoms  after   wounds   of   hea't, 

IQ2 

of  chronic  purulent  otitis,  29 

Retention  swellings  of  kidney,  457 
Retrobulbar       fatty       tissue,       venous 
thrombosis  of,  50,  6i. 


Retroflexion  of  gravid  uterus  causing 
constipation,  407 

—  — ■  —  causing   ileus,   353 
Retropharyngeal  abscess,  91,   114 
,  important    diagnostic    signs   of, 

123,  124 
Retroperitoneal  inflammation,   266 
Retrotonsillar   abscess,   91 
Rhagades  on  tongue,  nature  of,  107 
Rheumatism  of  ankle,  725,  726 

—  elbow,  571 

—  hip,  639,  651,  654 
— -    knee,  679,  681 
,  ankylosing,  686 

—  shoulder,  550,  552 
— ■    wrist,  589 

—  — ,  chronic,   589,   590 
Rhinoscleroma,    103 

Ribs,  chondritis  of,  after  typhoid,  213 

— ,   fractures  of,    187 

— ,  gumma  of,  213 

— ,  ostitis  of,  213 

— ,  protuberance  of,  528,  529,  531,  532 

— ,  tuberculosis  of,  213,  222 

Rickets,  bone  changes  in,  591,  636 

— ,  protuberance  on  ribs,   due  to,   532 

Rider's  bone,  658 

Risus   sardonicus  in   tetanus,   75 

Rodent  ulcer  of  face,  68,  6q,  70 

Rontgen  dermatitis  of  hand,  601 

Roser-Nelaton's  line,  determination  o/, 
612 

— in   congenital   dislocation   of 

hip,  632 

Rotation  dislocation  of  cervical  verte- 
bra, 182,  183 

■ —    fracture  of  thigh,  623,  624,  625 


Sacral  tuberculosis,  517 
Sacro-lumbar  tumours,  congenital,  486 
Salivary  glands,  swelling  of,  89 

,  diagnosis    from    tumours    of 

neck,   140 
—    stones     in     Steno's     duct,     causing 

acute  swelling  of  parotid,  62 
Wharton's     duct,     causing     in- 
flammatory      swelling       of       sub- 
maxillary,  132 
Salpingitis,  273 

— ,   diagnosis  from  appendicitis,  276 
Sarcoma  of  abdominal  wall,  376 


50 


//■ 


INDEX 


Sarcoma  of  arm,  572,  574 
^-    back  of  neck,  175 

—  bladder,  467 

—  cervical  glands,   170 

—  clavicle,  212 

—  diploe,  57 

—  femur,  657,  661,  665 

—  gluteal  region,  680 

—  gum,  94 

—  hand,  600 

—  kidneys,  457 

— ■    knee-joint,  684,  687 
— ■    lower  jaw,  87,  88 
— ■    lung,  207,  208 
— ■    mamma,  232,  233 

—  •    mediastinum,  207 
— ■    neck,  170 

—  — ,  pulsating,   163 

—  nose,  07 

—  OS  calcis,  726,  73g 

—  parotid  gland,  169 

—  patella,  687 

—  pelvis.  480 

—  penis,  475 

—  pharynx,  96 
— ■    prostate,  470 

— •    rectum,  409,  411 

—  sacral  region,  486 
— ■    scapula,  214 

— .    scrotum,  415 

—  shoulder,  553 

—  skull,  57 

— ■    spermatic  cord,  416 
— ■     spinal  cord,    509 

—  spleen,  331 

— ■    submaxillary  gland,   170 

—  testicle,  422 

—  thigh,  637,  658,  659 

—  thorax,  217,  218 

—  thyroid,   1 54 

—  tibia,  699,  700,  705 
— -    tongue,    io5 

—  tonsillar  region,  95 

—  trachea,   121 
— •    umbilicus,  374 

—  upper  jaw,  83,  84 

—  vascular  sheaths  of  neck,  171 
— •    vertebral  column,  509 
Scalp,  fibroma  of,  55 

— ,  gumma  of,  56,  58 
— ,  sebaceous  cysts  of,  55,  56,  57,  58 
Scaphoid  of  foot,  fracture  of,  721 
— ^    hand,  fracture  of,  584,  587 


Scapula,  fracture  of,  545,  546 
— ,  osteo-myelitis  of,  210 
— ,  sarcoma  of,  214 
— ,  tuberculosis  of,  214 
Scarlatinal  arthritis  of  hip,  644 

shoulder,  550 

School  scoliosis,  532 

Sciatica,  689-693 

--,  diagnosis    from    hip    disease,    652, 

654 
— ,  scoliotic,   522,   524,  691 
Scirrhus  of  breast,  225,  226 
Sclerosis,  multiple,  paraplegia  in,  509 
Scoliosis,  523,  524,  525,  527,  528,  529, 

530,  531 
— ,  causes  of,  532 
— ,  complete,   531 
— ,  fixed,  531 

—    ischiodica,   522,   524,  691 
— ,  mobile,   531 

— ■    of  dorsal  vertebree,  primary,  532 
Scrofula,    tubercular    lymphoma,     156 
Scrotum,  acute  inflammation  of,  414 
— ,  carcinoma  of,  415 
— ,  contents,  415 
— ,  dermoid  of,  415 
— ,   elephantiasis  of,  415 
— ,  fibroma  of,  415 
— ,  Ij^mphangioma  of,  415 
— ,   sarcoma  of,  415 
— ,  sebaceous  cyst  of,  415 
— ,  swellings  of,  414 
— ,  tumours  of,  414 
— ,  urinary  infiltration  of,  414 
Scurvy,  gangrene  in,  91 
— ,  haemorrhage  from  gums  in,   100 
Sebaceous  cyst  of  face,  63,  64 

•    hand,  599 

— •  —    neck,  165,   174 

•    penis,  475 

— •  — ■    root  of  nose,  64 

■    scalp,  55,  56,  57 

,  malignant    degeneration    of. 

58 
— ■  —    scrotum,  415 

skin  of  back,  216 

skull,  55 

•  —    with  sinus  formation,  55 

— ■  —    umbilicus,  378 

Segmental    diagnosis    of    spinal    cord, 

405,  496,  400,  510 
Semilunar   bone^    dislocation    of,    579, 

583 


INDEX 


Semilunar     bone,     fracture     of,      585, 
586 

—  cartilage,  incarceration  of,  670,  678 
,  laceration  and  displacement  of. 

670 
Seminal  vesicles,  abscess  of,  431 
Sensation  in  vertebral  injuries,   490 

,  partial,  493,   494 

Sesamoid  in  knee-joint,  669 

—  of    tarsal    bones,    fracture    of,    723, 

724 
Shoulder,  rigidity  of,   549 
Shoulder-joint,  contusion  of,  546 
— ,  dislocation  of,  538,  539,  540 
— ,  elevated  level  of,  congenital,  523, 

525 
~,  fractures    of,    537,    538,    539,    540 
— ,  gonorrhoea  of,  551 
— ,  injuries  of  (examination  for),  537, 

538,  539 
— ,  inflammatory  processes,   547 
,  diagnosis    from    diseases    of 

bursa    and    of   joint,    547,    548 
— ,  primary   disease   of  bones   of,    553 
— ,   sprain  of,  546 

— ,  testing  movements  of,   548,   549 
— ,  tubercle  of,  551,  552 
Sigmoid,  cancer  of,  352 
— ,  stenosis  of,  356 
— ,  volvulus  of,  365 
Sigmoiditis,  275 
— ,  ulcerating,  342 
Sinus  at  umbilicus,  378 
— ,  cavernous,  thrombosis  of,  61 
— ■    from  biliary  tract,  378 
— ■    intestine,  378 
— •    rectum,  424,  425 

—  stomach,  378 

—  thyroid  gland,   139 

—  urachus,  2)11 

— •    vitelline  duct,  2>T] 

—  frontal    phlegmon,    arising    there- 
from, 60 

—  in  perinseum,  424,  425 

— ,  longitudinal,  angioma  of,  54 
^,  maxillary,     chronic     inflammation 
of,  82 

—  of  abdomen,  2>~~i  3/8 

—  branchial  cleft,  138 

—  inguinal  region,  379 

—  urinary  tract,  378,  426 

—  on  neck,  136 

J  actinomycotic,   136 


Sinus  on  neck    (complete   and  incom- 
plete), 139 

,  congenital,   137,   138 

— ■  — ,  gummatous,  136 

— •  — ,  traumatic,  136 

— -  — ,  tubercular,   136 

— ,  pericranial,  blood  cyst  of,  53 

— ,  secretions  of,  378 

—  thrombosis,    after    aural    suppura- 
tion, 29,  32,  33 

Sinusitis,  acute,  60 

— ,  chronic,  60 

— ,  frontal,  60 

Situs  inversus  of  unpaired  abdominal 

viscera,  236 
— •  — ,  partial  inferior,  236 
Skin  appendages  in  front  of  ear  and 
on  face,  64 

—  cancer  of,  on  foot,  740 

,  on  face,  69,  70,  71 

,  on  hand,  601 

,  on  umbilical  region,  374 

— •    reflexes  in  spinal  injuries,  493 

—  -,  seborrhoea  of,  58 

,  on  forehead  and  temples,  71 

Skull,    acute    inflammatory    processes 

on,   51 
— ,  base  of,  fibroma  of,  96,  97 
— ■  — ,  fractures  of,  3,  6 

—  — ,  nerves  at,  46 
— -  — ,  sarcoma  of,  96 

— ,  chronic  inflammatory  swellings  of, 
56 

—  — ,  ulcerating  growths  of,  58 

— ,  demarcation  of  cortical  centres  on 

the  surface  of,  47,  48,  49 
— ,  dermoid  of,  53,  54 
— ,  erysipelas  of,   51 
— ,  exploration  of,  16 
— ,  fissures  of,  6 
— ,  fractures  of,   i 

,  direct  symptoms,  2 

,  indirect  symptoms,  4 

—  — ,  position  and  course  of,  5,  6 
— ,  gummata  of,  56,  58 

— ,  injuries   of,    causing    epilepsy,    34, 

35 

— ,  new  growths  of  internal  layer,  22 

— ,  osteoma  of,  55 

— ,  osteomyelitis  of,  51 

— ,  periostitis  of,   51 

— ,  phlegmon  of  glands  of,  51 

^-,  sarcoma  of,  56,  57 


774 


IXDE^t 


Skull,  sarcoma  of,  periosteal,  57 

— ,  sebaceous  cyst  of,  55 

— ,  secondary  growths  of,  57 

— ,  tubercle  of,  56 

Small  intestine,  gall  stones  in,  275 

,  intussusception     of,     confusion 

with,  appendicitis,  275 
,  palpation  of,  23Q 

—  — ,  stenosis  of,  349,  355,  359 

—  through  fibro-sarcoma,  348 

,  torsion  of,  364 

,  tumours  of,  28g 

Solitary  kidney,  displacement  of,  235 
Spermatic  cord,  hydrocele  of,  385,  415 
,  diagnosis       from       inguinal 

hernia,  388 

,  tumours  of,  415 

Spermatocele,  419,  420 

Sphincter  of  bladder,  ulceration  of,  as 
a  cause  of  incontinence,  432 

Spina  bifida,  218,  481 

— •  — ,  forms  of,  482 

occulta,  485 

— ■ ,  club  foot  in,   735 

,  pes  cavus  in,  735 

Spinal  caries,  50Q,  511 

— ■  — ,  ankylosing,   521 

causing  bending  of  spine,  522 

— •  — ,  cervical,  515,  51G,  517 

— • ,  commencing,   513,   514 

commencing,   512,   313 

— ■  — ,  diagnosis   from  peritonitis 

— ■ spinal  cord  tumour,  509 

sarcoma  of  vertebra,   510 

,  non-tubercular,   520 

,  ankylosing,   521 

,  secondary    after    pneumonia 

and  typhoid,    521 

of  dorsal  vertebrae,  513,  516,  517 

lumbar  vertebrae,  516,  517 

,  osteo-myelitic,    521 

-J  posture  of  head  in,  180,  514 

,  syphilitic,  521 

,  traumatic,  520 

,  tubercular,  181,  215,  511,  515 

,  in  adults,  513 

,  in  children,  511 

— -  —    with  burrowing  abscess,  515 

■    cord  symptoms,  519 

— •  — -  without  protuberance  and  with- 
out burrowing  abscess,  511 

—  cord,  Brown-Sequard's  syndrome, 
494,  508 


Spinal  cord,  compression  of,  494,   526 
— -  — ,  congenital  clefts  in,  485 

,  contusion  of,  494 

— •  — ,  gumma  of,  510 

,  haemorrhage  in,  495 

,  injuries  of,  489 

—  —  — ,  complete,  493 

— ,  partial,  494 

,  non-traumatic  diseases  of,   507 

—  — ,  sarcoma  of,  510 

—  — ,  segmental    diagnosis,    495,    496, 

499 

,  solitarj-  tubercle  of,  510 

,  tumours  of,  508,  509 

—  meninges,  innocent  growths  of,  510 
Spine  of  tibia,  detachment  of,  671 
— ■  — ■  — ,  normal  picture  of,  671 
Spleen,  abscess  of,  266,  330 
— ,  amyloid  disease  of,  331 
— ,  congenital  syphilis  of,  331 
— ,  displacement  of,  236,  238 
— ,  hypertrophy  of,  331,  332 
— ,  injuries  of,  247 
— ,   swelling  of,  in  diphtheria,  113 
— ,  tumours  of,  331 
Sporotrichosis  of  elbow  region,  571 
Staphylomycosis  of  breast,  221 

:2  —    medulla  of  femur,  662,  665 

— ■    tibia,   703 

Sterno-clavicular  joint,  injuries  of,  53.1 

Sterno-mastoid,  gumma  of,  140 
263      — .  — J  myositis  of,   133 

— •  — ,  tuberculosis  of,    140 

Sternum,  abscess  of,  211 

— ,  fracture  of,   188 

,  transverse,     in     upper     portion, 

505 
— ,  gumma  of,  213 
— ,  malignant  growth  of,  213 
— ,  osteo-myelitis  of,   133 
— ,  tubercle  of,  212,  213 
Stomach,  abnormalities  in  position  of, 

236,  242,  293 
--,  cancer  of,  302,  303,  305 

—  —    at  cardia,  306 

•    fundus,  310 

pylorus,  311 

—  — ,  chemistry  in,  309 

,  varieties  of,  310,  311 

— ,  cicatricial    stenosis    of,    299,    300, 

301,  303 
— ,  contusion  of,  245,  247 
— ,  dilatation  of,  302,  303 


I 


liS'DEX 


775 


Stomach,    foreign  bodies   in,    292,    293 
— ,  gunshot  wounds  of,  252,  253 
- -,  haemorrhage  from,  296,  308 

—  hour-glass,  302,  303,  304 
— ,  perforation  of,  296 

,  differential  diagnosis,  299 

,  local  symptoms,  298 

— .  shape   and   position  of,    abnormal, 

292,  302,  303 
■  — ,  normal,  240 

— ,  sinuses  from,  378 

— ,  skiagram  of,  302,  303 

in  retention  of  contents,  301 

,  technique  and  diagnostic  signi- 
ficance, 292 

— ,  surgical  diseases  of,  291 

,  with    peritoneal    signs,    265, 

266 

—  -,  ulcer  of,  294,  302 

,   diagnosis  from  cholecystitis,  316 

•    ileus,  358 

—  —    indolent,  295 

,  perforating,  266,  296,  297 

,  uncomplicated,  294 

Stomatitis,  gangrenous,  76,  91 

— ,  mercurial,  76 

Stones  of  kidnej',  infected,  455 

,  non-infected,  453 

Stools,  blood  in,  245,  349,  407 

— ,   diagnostic     significance     of     their 

consistence,  407,  408 
— ,  incontinence  of,  492 
— ,  pus  in,  350 
— ,  retention  of,  349 
— ,  shape  of,  348,  349,  407 
Streptococcal       laryngitis,       diagnosis 

from  diphtheria,  1 1 1 
Streptomycosis  of  breast,  221 
Stricture  of   rectum,    gonorrhoeal    and 

syphilitic,   407 
— ,  urethral,  examination  of,  439 
Styloid  process  of  radius,  fracture  of. 

577,  578 
— •  —    ulna,  fracture  of,  577,  578 
Subluxation  of  foot,  713,  715 

—  radius,  563 

~,  Volkmann's,   734 

Submaxillary  gland,  inflammation,  132 

,  chronic,  166 

,  mixed  tumours  of,  167 

— ■  — ,  sarcoma  of,  169 

,  tubercle  of,   167 

Surgical   emphysema  after   injuries  to 
air  passages,  116 


Surgical  emphysema,  lung  injuries,  189 
Swallowing,  difficulty  in,  122 

—  — ,  position  and  nature  of  obstruc- 

tion, 127 
,  through     aft'ections     of    mouth 

and  throat,  122,  123,  124 
._..  — .  —  foreign  bodies,  123 
•  — ■    laryngeal  diseases.   118 

—  ^  — ■    oesophageal  disease,   124 
Sweat  glands  of  axilla,  inflammation, 

211 
Synovitis  of  ankle,  tubercular,  725,  726 
-    knee,  osteo-myelitic,  681 

—  — ,  rheumatic,  681 

,   syphilitic,  681 

Syphilis  insontium,  22,  90 

—  of  brain,  22 
— •    elbow,  571 

—  epididymis,  419,  426 

—  face,  65,  71 

—  finger,  603,  608 

—  foot,  6g6,  725,  740 

—  hand,  605,  608 
— ■    intestine,  353 
— •    knee,  681 

—  large  intestine,  34: 

—  larynx,  120,   121 

—  leg,  695,  696,  70c 

—  lips,  64,  99 

—  mouth,  90,  99,   100 

—  neck,   136,  156 
— •    nose,  65,  66 

—  oesophagus,  130 
— •    palate,  95 

—  penis,  476,  478 

—  rectum,  341,  408 

—  testicle,  422 

— •    thoracic  wall,  211 

—  thyroid,  153 
— -    tibia,  701,  704 

—  vertebrae,  521 
Syringo-myelia,     hand    deformity    in, 

607 


Tabes,    diagnosis   from  perforation  of 

stomach,  299 
--  —    peritonitis,  262 
—  —    tumour  of  spinal  cord,  508 
Talipes,    729,   730,   731,   733,    734,   733, 

737 
Tar  cancer,  415 
Tear    ducts,    inflammation    of,   60,    61, 

167 


)76 


Index 


Tegmen  tympani,  suffusion  of,  6 
Temporal     lobe,      abscess     of,     after 

otorrhoea,  30 
— •  — ,  tumours  of,  24 
Tendon     reflexes,     condition     of,     in 

spinal  caries,  519 

— vertebral  injuries,  493 

Tenesmus  of  bladder,  432 

-in  stone,  462 

•    urinary  tubercle,  458 

— ■    rectum,  407 

— •  —    with  constipation,  407 

Teno-synovitis  of  hand,  588,  603 

,  gonorrhoeal,  603,  608 

— ,  tubercular,  589,  sqo,  599,  607 
Teratoma  of  pharynx,  97 
— -    sacral  region,  486 
Testicle,  gumma  of,  419 

hsematocele  of,  416,  420 

hydrocele  of,  387,  388,  420 

infarction  of,  418 

inflammation  of,  416,  417 
— ,  metastatic,  417 

injuries  of,  416 

spermatocele  of,  419,  420 

strangulation  of,  399 

syphilis  of,  422 

torsion  of,  399,  418 

tumours  of,  422 
Tetanus  of  head,  with  facial  palsy,  75, 

Thigh,  abscess  of,  518 

— ,  aneurism  of,  658 

— ,  blood  cysts  of,  660 

— ,  dislocations  of,  615-620 

• — ■  — ,  congenital,  631 

— ,  fractures  of,  621,  631 

— ,  muscular  swelling  of,  658 

— ,  osteo-myelitis  of,  656 

— ,  tumours  of,  656,  657,  659 

5  in  epiphysis,  661 

diaphysis,  664 

Thorax,   angioma   of,   216 

— ,  bones  of,  fracture,  186,  187 

— ,  burrowing  abscess  of,  517 

— ,  empyema,   breaking  through,   209 

■^5  enchondroma  of,  218 

■■ — ,  fibroma  of,  216 

— ,  inflammatory    processes    of,     210- 

216 
--,  injuries  of,  187-188 
^-,  lipoma  of,  211,  215,  217,  517 
— i  lymphangioma  of,  217 


Thorax,    malignant    tumours    of,    2ii, 
213 

—  muscle,  gumma  of,  212 
— ,  osteoma  of,  218 

— ,  osteo-myelitis  of,  210 
— ,  sarcoma  of,  216,  217,  218 
— ,  sebaceous  cyst  of,  216 
— ,  surgical  diseases  of,  186 

■  — ,  external,  208 

— ,  internal,   199 

■ — ,  tuberculosis  of,  209,  212 
- — ,  tumours  within,  199 

without,  208,  216 

Thrombo-phlebitis  of  transverse  sinus 

in   aural   suppuration,   29,   32,   2>Z 
Thymic  death,  201 
Thymus,     condition     of,     in     Graves's 

disease,  146 
— ,  hypertrophy     of  :     diagnosis,     200, 

201 
Thyroid,    cancer  :    secondary   deposits, 

57,   155 

— ,    symptoms,    121,    155 

--    fistulse,   139 

—  gland  in  obesity,  175 

,  inflammation  of,   133,   151 

,  simple  hyperplasia  of,   141,   142 

,  tumours  of,   154 

Tibia,  chronic  abscess  of,  703,  704 

—  ,  dislocation  of,  676,  712 
,  posterior,  685 

,  at  lower  end,  706,  707,  711,  713 

— ,  fractures  of,  675,  676 

— ,  laceration  of  crucial  ligaments, 

675 
— ,  normal,  704 
— ,  osteo-myelitis    of,    699,    700,    701, 

702,  703 
— ,  periostitis  of,  703 

• ,  syphilitic,   704 

— 5  syphilis  of,  701,   703 

— ,  tuberculosis  of,  703,  704,  726 

— ,  tumours  of,  697,  699,  700 

Tic,  rotatory,   186 

Toe-nail,  ingrowing,  740 

Toes,  chondroma  of,  738 

— ,  deformities  of,  Tzi 

— ,  gangrene  of,  728 

Tongue,    actinomycosis    of,    105,    io6j 

107 
— ,  angioma  of,   105 
— ,  cancer  of,  99,  108,  109 
— 3  dry   (significance  of),    104 


INDEX 


777 


Tongue,  fibroma  of,   105 

— ,  gumma  of,  105,  106,  107 

— ,  leucoplakia  of,   104 

— ,  lipoma  of,  105 

— ,  lymphangioma  of,  105,  106 

— ,  primary  chancre  of,  107 

— ,  sarcoma  of,   106 

— ,  swelling  of,  go,  104 

— ,  tuberculosis  of,  105,  106,  107 

Tonsil,  cancer  of  loi,   103 

,  metastasis  in  neck,    161 

— ,  gumma  of,   loi 

— ,  mixed  tumours  of,  qs 

— ,  primary  chancre  of,   102 

— ,  sarcoma  of,  95 

— ,  tuberculosis  of,   loi 

Tonsillitis,   iii,   112 

Torticollis,   180,  184,  185,   186 

Trachea,    surgical    diseases   of,    acute, 

III 

,   chronic,   118 

Trismus,  75 

Trochanter,     fractures    of,     622,     623, 

624 
— ,  level  of,  612,  632 
,  in    congenital    dislocation,    632, 

636 

,  coxa  adducta,  639,  640 

Tubal   pregnancy,   ruptured,   271,   273, 

274 
,  diagnosis  from  gastric  ulcer, 

299 

— ileus,  358 

Tubercle  of  abdominal  wall,  376,  2>n 

—  arm,   573,    576 

—  bladder,  463,  465 

—  brain,  17,  22 

—  cervical  vertebrae,   134,   136,  511 

—  elbow,  509,  570,  571,  572 

—  epididymis,  419,  420 

—  femur,  653,  658,  662 

—  finger,  608 

—  floor  of  mouth,  99,  100 

—  foot,  725,  726,  727,  728,  740 

—  gum,  79,  100 

—  hand,  607,  600 

—  hernial  sac,  402 

—  hip,  645 

—  humerus,  551,  573,  575,  376 

—  inguinal  glands,  375 

—  intestine,  351 

—  jaw,  60,  76,  79,  80,  81,  83,  84 
~    kidneyj  450,  451 


Tubercle  of  knee,   680,   681,   682,   684 
---     lachrymal  sac,  61 

—  larynx,   119,   120,   121 

—  leg,   703 

—  lobule  of  ear,  72 

—  lungs,  suppurative,   198,  209 

—  mamma,  221,  222 

—  neck,   134,   138,  152 

—  nose,  103 

—  OS  calcis,  726,  728 

—  palate,    103 

—  parotid,  167,  168 

—  pelvic  bones,  651 

—  peritoneum,  264,  281 

—  pre-patellar  bursa,  687. 

—  prostate,  471 

—  rectum,  341,  408 
--    ribs,  213 

—  scapula,  214,  552 

—  shoulder,  550,  551 

—  -    skull,  56 

—  sternum,  212,  213 

—  subdeltoid,  550 

-     submaxillary  gland,   167 

—  tendon  sheaths  of  hand,  599 

—  thorax,  209,  211 

—  thyroid,    153 

—  tibia,  703,  704 

,  at  lower  end,  725,  726 

—  tongue,   105,   107 

—  tonsillar    region,     diagnosis    from 
gumma,    loi,    102 

—  urinary  passages,   458,   461 

—  vertebrae,  181,  215,  511,  515 

—  wrist,  589,  590,  591,  599 
Typhoid  fever,  arthritis  of  hip,  after, 

644 

vertebral  joints,  after,  521 

,  ostitis    and    chondritis    of    ribs, 

after,  213 
Typhlitis,    ulcerative,   342 


u 


Ulcers  of  concha  of  ear, 

—  face,   62,   64 

—  foot,  696,  739 

—  gum,  100 

—  intestine,  353,  358 

—  larynx,   115,   119,   120 

•  -  leg,  693,  694,  695,  696 

—  oral  cavity,  98 

—  peni5,  4753  47^ 


778 


INDEX 


Ulcers  of  scalp,  s8 

—  scrotum,  415 

—  stomach,  294 

—  tongue,    106 

—  tubercular,  79 

Ulnar  paralysis,  posture  of  hand  and 

fingers  in,  593,  598 
Umbilical  cord,  hernia  of,  371,  ■i']2> 

—  hernia,   372 

,  in  cirrhosis  of   liver,  372 

,  strangulation  of,  403 

Umbilicus,   abscess  of,  378 

— ,  concretions   in,   378 

— ,  fistulse     of,     congenital     and     ac- 
quired, 378 

— ,  tumours  of,  374,  378 

Urachus,  cysts  of,  Z12> 

— ,  fistulae  of,  377 

Ureter,  catheterism  of,  427,  441 

— ,  in  urinary  tuberculosis,  459 

Ureteral   stones,   453 

Urethra,  fistulae  in,  426 

— ,   foreign  bodies  in,   430 

— ,  haemorrhage  from,  435 

— ,  injuries  of,   472,   473 

,  in  fractured  pelvis,  474,  630 

— ,  obstruction  of,  430 

— ,  stricture  of,  439,  44° 

,  of  gradual  onset,  431 

Urethritis,    differential    diagnosis    in, 
428 

Urethroscopy,  439 

Urinary  disturbances,  429,  440 

—  — ,  difficult    and    painful    micturi- 
tion, 429,  432 

,  involuntary   micturition,   431 

— ,  fever,  452,  455 

— ,  fistulas,  378,  379,  4^6,  427 

— ,  gravel,  436,  433 

— ,  tract,  surgical  diseases  of,  427 

,  local  symptoms,  445 

,  tuberculosis  of,  434,  435)  458 

Urine,  albumin  in,  452,  459 

— ,  blood  in,  249,  251,  435,  454,  47° 

— ,  examination  of,  434,  435,  43^ 

— ,  extravasation  of,  414 

,  in  injury  of  kidneys,  249 

J  rupture  of  bladder,  250,  251 

• ,  urethral  injuries,  473 

^,  pus  in,  433,  434,  449 

■ — ,  retention  of,  430 

,  results,  447,  464 

— ,  sugar  in,  329 


Urticaria,  in  hydatid  disease,  326 

— ,  hydronephrosis,  436 

Uterus,  cancer  of,  causing  intestinal 
obstruction,  353 

— ,  cystoma  of,  290 

— ,  fibrous  myoma  of,  289 

— ,  inflammation   in    and    around,    266 

— ,  pregnant,  diagnosis  from  ab- 
dominal tumour,  290 


V 


Varicocele,  388 

— ,  with  atrophy  of  testicle,  389 

Varicose  veins  of  leg,  693,  694,  697, 
698 

■ thigh,  657 

Varix,  aneurismal,  diagnosis  from 
arterio-venous  aneurism,   164 

Vein,  internal  jugular,  thrombo- 
phlebitis of,  2)2, 

— ,   saphenous,  dilatations  of,  392 

Verruca  senilis,   58 

Vertebral  column,  arthritis  deformans 
of,   521 

,   congenital    deformities   of,   481, 

523 
,   curvatures    of,     519,     522,     525, 

526 
,  dislocations    of,    176,    500,    502, 

503 
,  fractures  of,  176,  488,  501,  502, 

503 
,  injuries   of,   489,   493,   494,   495, 

499,  501,  505,  506 

,  osteo-myelitis  of,  180,  576 

,  partial  injuries  of,  493,  494 

,  rigidity  of,  521 

,  sarcoma  of,  509 

,  sprains  of,  487,  488 

— ■  — ,  syphilis,  tertiary,  of,  521 

—  — ,  tubercular  abscess  of,   134,   140. 

215,  515,  519 

—  — ,  tumours  of,  508,   510 

— ,  diagnosis         from         spinal 

caries,  509 
— ,  injuries,  examination  of,  489 

•    for  movements,  490 

•     reflexes,   492,   493 

— ■     sensation,   490,   491 

—    vasomotor  state,  491 

— • ■     visceral   functions,  492 

Vestibular  nqrve,  disturbances  of,  43 


INDEX 


779 


Volvulus,  364 

— 5  ileo-csecal,  365 

—    of  sigmoid  flexure,  365 

w 

Warts,  soft,  of  face,  64 

Whitlow,  602,  603,  604 

Wrist,  abnormal  postures  of,  595 

— ,  arthritis  of,  588,  5qo 

— ,  bones  of,  fracture  of,  584,  585 

— ,  dislocation,  fracture  of,  584,  585 

of,  579,  583 

— ,  gonorrhoea  of,  589 
— ,  injuries  of,  577 

,  scheme,  587 

— ,  normal,  583 

— ,  rheumatism  of,   589 


Wrist,  rheumatism  of,  chronic,   589 
— ,  sprain  of,  576,  577,  586 
— ,  tuberculosis  of,  589,  590,  592,  599 
Wry-neck,  180,  184,  185,  186 

X 

Xanthelasma  of  face,  64 


Y-SHAPED  fracture  of  femoral  con- 
dyles, 673,  675,  676 

fibula,  711 

head  of  humerus,  545 

lower    end    of    humerus,     556, 

564,  568 

neck  of  femur,  623 


I 


COLUMBIA  UNIVERSITY  LIBRARIES  (hsi.stx) 

RD35QU3131913C.1 

Clinical  i:,-;  :a  -:  ^::- -,-  -, '--  -•  r'pnK 


2002120780 


